Pancreatitis

Etiology:
Acute-
Biliary tract disease & alcoholism account for > 80% of acute pancreatits cases.
Chronic-
70- 80% result from alcoholism, 15-25% are idiopathic- recent data suggests that alcohol becoming less of a cause. Less common causes: hereditary pancreatitis, hyperparathyroidism, obstruction of main pancreatic duct caused by stenosis,stones, or cancer. M. Rikard

Signs/Symptoms:
Acute- steady, boring upper abdominal pain, usually severe enough to require large doses of parenteral opioids. Pain radiates through back, rarely in abdomen first. Gallstone pancreatitis- pain develops sudden. Alcoholic pancreatitis- pain develops over a few days. Pain persists for several days. Sitting up and leaning foward may reduce pain. Coughing, vigorous movement, and deep breathing may accentuate it. Nausea and vomiting are common.
Chronic- episodic abdominal pain. 10-15% have no pain and present with malabsorption. Pain is epigastric, severe, and may last man hours or several days. 6-10 yr episodes typically subside as the acinar cells that secrete pancreatic digestive enzymes are progressivley destroyed. <10% of normal lipase and protease secretions, patient develops steatorrhea, passing greasy stools or even oil droplets, and creatorrhea. Symptoms of glucose intolerance may appear at this time. M. Rikard

Method of Diagnosis: Acute-
Serum Markers ( amylase, lipase); once diagnosed, CT usually done
Suspected when severe abdominal pain occurs especially in patients with significant alcohol use or known gallstones. Conditions causing similar symptoms include perforated gastric or duodenal ulcer, mesenteric infarction, strangulating intestinal obstruction, dissecting aneurysm, biliary colic, appendicitis, diverticulitis, inferior wall MI, and hematoma of the abdominal muscles or spleen.

Diagnosis is made by clinical suspicion, serum markers (amylase and lipase), and the absence of other causes for the patient's symptoms. Thus, a broad range of tests is done, typically including CBC, electrolytes, Ca, Mg, glucose, BUN, creatinine, amylase, and lipase. Other routine tests include ECG and an abdominal series (chest, flat, and upright abdomen). A urine dipstick for trypsinogen‑2 has sensitivity and specificity of > 90% for acute pancreatitis. Ultrasound and CT are not generally done specifically to diagnose pancreatitis but are often used to evaluate acute abdominal pain (see Acute Abdomen and Surgical Gastroenterology: Testing).

Chronic-
Clinical suspicion
Abdominal CT
Sometimes MRCP, endoscopic ultrasound, or ERCP

Diagnosis can be difficult because amylase and lipase levels are frequently normal because of significant loss of pancreatic function. In a patient with a typical history of alcohol abuse and recurrent episodes of acute pancreatitis, detection of pancreatic calcification on plain x‑ray of the abdomen may be sufficient. However, such calcifications typically occur late in the disease and then are visible in only about 30% of patients. In patients without a typical history, pancreatic malignancy must be excluded as the cause of pain: abdominal CT is recommended. CT can show calcifications and other pancreatic abnormalities (eg, pseudocyst or dilated ducts) but still may be normal early in the disease.

The primary options for patients with normal CT findings include ERCP, endoscopic ultrasound, and secretin pancreatic function testing. These tests are quite sensitive, but ERCP precipitates acute pancreatitis in about 5% of patients. Magnetic resonance cholangiopancreatography (MRCP) may prove an acceptable alternative.

Late in the disease, tests of pancreatic exocrine function become abnormal. A 72‑h test for stool fat is diagnostic for steatorrhea but cannot establish a cause. The secretin test collects pancreatic secretions via a duodenal tube for analysis but is done in only a few centers. Levels of serum trypsinogen and fecal chymotrypsin and elastase may be decreased. In the bentiromide test and the pancreolauryl test, substances are given orally, and urine is analyzed for cleavage products generated by pancreatic enzymes. All such exocrine tests are less sensitive than ERCP or endoscopic ultrasound early in the disease.

**Risk Factors:
*Modifiable: Acute-
Drugs-ACE inhibitors, asparaginase Some Trade Names
ELSPAR, azathioprine Some Trade Names IMURAN, 2´, 3´-dideoxyinosine, furosemide Some Trade Names
LASIX, 6- mercaptopurine Some Trade Names PURINETHOL, pentamidine Some Trade Names NEBUPENT PENTAM 300, sulfa drugs, valproate Some Trade Names DEPAKENE
Infectious
Coxsackie B virus, cytomegalovirus, mumps

Mechanical/structural
Gallstones, ERCP, trauma, pancreatic or periampullary cancer, choledochal cyst, sphincter of Oddi stenosis, pancreas divisum

Metabolic
Hypertriglyceridemia, hypercalcemia (including hyperparathyroidism), estrogen use associated with high lipid levels

Toxins
Alcohol, methanol

Other
Pregnancy, postrenal transplant, ischemia from hypotension or atheroembolism, tropical pancreatitis

*Non-Modifiable:** Acute-
Multiple known gene mutations, including a small percentage of cystic fibrosis patients

Prevention:People who are susceptible to pancreatitis should avoid any alcohol consumption.If the cause is gallstones and your gallbladder has not been removed, avoid fatty foods, such as butter and fried eggs

Supplements Commonly Used: supplement pancreatic enzymes; supplement fat-soluble vitamins and vitamin B-12;You may address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, D, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc and selenium.
Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 - 2 tablespoonfuls oil daily, to help decrease inflammation and improve immunity.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant and immune activity.
Vitamin C, 1 - 6 gm daily, as an antioxidant. Vitamin C may interfere with vitamin B12, so take doses at least 2 hours apart. Lower the dose if diarrhea develops.
Probiotic supplement (containing Lactobacillus acidophilus and other beneficial bacteria), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need refrigeration.
Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.
Resveratrol (from red wine), 50 - 200 mg daily, for antioxidant effects

**Labs Appropriate to Disease:
*Normal Values Range:Plasma Glucose: 65-110
WBC: 5-10 X 10(3)
Amylase: 25-125uL
AST: 5-140 u/L
LDH: 313- 618 u/L
*Values in the Disease: Acute- Plasma glucose > 200 mg/dL (> 11.1 mmol/L)
Serum LDH > 350 IU/L
AST > 250 UL
WBC count > 16,000/μL
Within 48 h of admission:

Hct decrease > 10%
BUN increase > 5 mg/dL (> 1.78 mmol/L)
Serum Ca < 8 mg/dL (< 2 mmol/L)
Pao2 < 60 mm Hg (< 7.98 kPa)
Base deficit > 4 mEq/L (> 4 mmol/L)
Estimated fluid sequestration > 6 L

Serum amylase and lipase concentrations increase on the first day of acute pancreatitis and return to normal in 3 to 7 days. Lipase is more specific for pancreatitis, but both enzymes may be increased in renal failure and various abdominal conditions (eg, perforated ulcer, mesenteric vascular occlusion, intestinal obstruction). Other causes of increased serum amylase include salivary gland dysfunction, macroamylasemia, and tumors that secrete amylase. Both amylase and lipase levels may remain normal if destruction of acinar tissue during previous episodes precludes release of sufficient amounts of enzymes. The serum of patients with hypertriglyceridemia may contain a circulating inhibitor that must be diluted before an elevation in serum amylase can be detected.

Amylase:creatinine clearance ratio does not have sufficient sensitivity or specificity to diagnose pancreatitis. It is generally used to diagnose macroamylasemia when no pancreatitis exists. In macroamylasemia, amylase bound to serum immunoglobulin falsely elevates the serum amylase level.

Fractionation of total serum amylase into pancreatic type (p‑type) isoamylase and salivary-type (s‑type) isoamylase increases the accuracy of serum amylase. However, the level of p‑type also increases in renal failure and in other severe abdominal conditions in which amylase clearance is altered.

The WBC count usually increases to 12,000 to 20,000/μL. Third space fluid losses may increase the Hct to as high as 50 to 55%, indicating severe inflammation. Hyperglycemia may occur. Serum Ca concentration falls as early as the first day because of the formation of Ca “soaps” secondary to excess generation of free fatty acids, especially by pancreatic lipase. Serum bilirubin increases in 15 to 25% of patients because pancreatic edema compresses the common bile duct.

Imaging: Plain x‑rays of the abdomen may disclose calcifications within pancreatic ducts (evidence of prior inflammation and hence chronic pancreatitis), calcified gallstones, or localized ileus in the left upper quadrant or the center of the abdomen (a “sentinel loop” of small bowel, dilation of the transverse colon, or duodenal ileus). Chest x‑ray may reveal atelectasis or a pleural effusion (usually left-sided or bilateral but rarely confined to the right pleural space).

Ultrasound should be done if gallstone pancreatitis is suspected (and another etiology is not obvious) to detect gallstones or dilation of the common bile duct (which indicates biliary tract obstruction). Edema of the pancreas may be visualized, but overlying gas frequently obscures the pancreas.

CT with IV contrast is generally done to identify necrosis, fluid collections, or pseudocysts once pancreatitis has been diagnosed. It is particularly recommended for severe pancreatitis or if a complication ensues (eg, hypotension or progressive leukocytosis and elevation of temperature). IV contrast facilitates the recognition of pancreatic necrosis; however, it may cause pancreatic necrosis in areas of low perfusion (ie, ischemia). Thus, contrast-enhanced CT should be done only after the patient has been adequately hydrated.

If pancreatic infection is suspected, fluid obtained by percutaneous CT‑guided needle aspiration of cysts or areas of fluid collection or necrosis may reveal organisms on Gram stain or culture. The diagnosis is supported by positive blood cultures and, particularly, by the presence of air bubbles in the retroperitoneum on abdominal CT. The advent of magnetic resonance cholangiopancreatography (MRCP) may make the selection of pancreatic imaging simpler.

*Nutritional Significance:**

General Dietary Prescription: Acute-Easily digestible foods, low fat foods, small meals, adequate protein intake
Chronic- Provide oral diet as in acute; TF can be used when oral diet is inadequate
Specific Foods to Include:
Some evidence suggests that increasing your intake of antioxidants (found in fruits and green vegetables) may help protect against pancreatitis or alleviate symptoms of the condition. Several studies have explored the role of free radicals, which are by-products of metabolism that are harmful to cells in the body, in pancreatitis. Antioxidants are often recommended to help rid the body of free radicals, and low levels of antioxidants in the blood may make someone more likely to develop pancreatitis. Alcohol-induced pancreatitis is linked to low levels of antioxidants as well.

Specific Foods to Avoid: Foods high in fat

Reccomended Prescription Drug Therapy:Acute-Drugs, including adequate analgesia and acid blockers
Antibiotics for pancreatic necrosis
Chronic: supplement pancreatic enzymes; supplement fat-soluble vitamins and vitamin B-12

Potential Food and Drug Interactions: Pancreatic Enzyme Oral
Take this medication by mouth with meals and snacks as directed by your doctor. Swallow the capsule whole. If swallowing is difficult, then the capsule may be opened and the contents mixed in a small amount of liquid or soft food that does not need to be chewed (e.g., applesauce). Do not mix the contents of the capsule with alkaline food or liquid (e.g., milk, ice cream, tea). Consult your doctor or pharmacist for more information about what foods/liquids to avoid when mixing. Swallow the food or liquid right away, making sure not to chew the medication. Drink a glass of water or juice after swallowing the food to make sure all the medication is swallowed. Do not save the medication mixture for later.

General Nutrition Education Objectives or Goals:
Following these nutritional tips may help reduce risks and symptoms:

Eliminate all suspected food allergens, including dairy (milk, cheese, eggs, and ice cream), wheat (gluten), soy, corn, preservatives, and chemical food additives. Your health care provider may want to test you for food allergies.
Eat foods high in B-vitamins and iron, such as whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell pepper).
Avoid refined foods, such as white breads, pastas, and sugar.
Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
Use healthy oils for cooking, such as olive oil or vegetable oil.
Reduce significantly or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily.
Exercise moderately for 30 minutes daily, 5 days a week.

M. Rikard

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