Clinical Case Database / Category: Patient Management

Management of acute pancreatitis

Publication details

Heather M Sowden BSc MBChB, Sonia Littlewood MBChB, MRCS
Foundation Years Journal, volume 4, issue 1, p.38 (123Doc Education, London, January 2010)

Abstract

Acute pancreatitis (AP) is an inflammatory condition of the pancreatic gland whereby pancreatic enzymes autodigest the pancreas. Although the exact mechanisms by which this process occurs is unknown, the presence of gallstones and excessive alcohol consumption are responsible for approximately 75% of attacks in the UK. Individuals typically present with acute epigastric pain that radiates through to the back, nausea and vomiting are also prominent features. The diagnosis is confirmed by a raised serum amylase, however, if individuals present more than 3 days after the onset of pain, the amylase may be normal and serum lipase measurements may be more useful. The majority of people will have mild self-limiting disease that requires supportive care only. However, of those with AP approximately 20% go on to have a severe attack characterised by the systemic inflammatory response syndrome (SIRS), and multi-organ dysfunction (MOD). Identifying early those who are likely to have a severe attack has been the driving force behind the development of scoring systems aimed to predict early those who will develop a serious attack. Those with both local and systemic complications will need to receive their care in a high dependency or intensive care unit environment and ideally be managed by multidisciplinary teams. Mortality from AP has a bimodal distribution with approximately half of the deaths occurring in the first 14 days from SIRS and MOD, which fails to respond to treatment. The second peak occurs at 3 months with MOD secondary to sepsis from infected pancreatic necrosis.

Access the Clinical Cases Database

A subscription is required to read the full article. Please subscribe using one of the options below.

Authors

Heather M Sowden BSc MBChB

FY1 in General Surgery, Dewsbury District Hospital, West Yorkshire
ugm3hms@doctors.org.uk

Sonia Littlewood MBChB, MRCS

SpR in General Surgery (Colorectal), Dewsbury District Hospital, West Yorkshire

References

1. Browse NL, Black J, Burnand KG, Thomas WEG (eds) (2005) Acute Pancreatitis, Browse's introduction to symptoms and signs of surgical disease, 4th edn. New York: Oxford University Press, pp. 399–400.
2. McKay CJ, Evans S, Sinclair M, et al. (1999) High early mortality rate from acute pancreatitis in Scotland, 1984–1995. Br J Surg 86:1302–1305.
3. Toh SK, Phillips S, Johnson CD (2000) A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England. Gut 46:239–243.
4. UK guidelines for the management of acute pancreatitis. UK working party on acute pancreatitis. Gut 2005, 54:1–9.
5. Matull WR, Pereira SP, O'Donohue JW (2006) Biochemical markers of acute pancreatitis. J Clin Pathol 59:340–344.
6. Frossard JL, Steer ML, Pastor CM (2008) Acute pancreatitis. Lancet 371:143–152.
7. Sternby B, O'Brien JF, Zinsmeister AR, DiMagno EP (1996) What is the best biochemical test to diagnose acute pancreatitis? A prospective clinical study. Mayo Clinic Proc 71:1138–1144.
8. Wilson C, Heath DI, Imrie CW (1990) Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems. Br J Surg 77:1260–1264.
9. Lund H, Tonnensen H, Tonnensen MH, et al. (2006) Long-term recurrence and death rates after acute pancreatitis. Scand J Gastroenterol 41:234–238.
10. Berry AR, Taylor TV, Davies GC (1981) Pulmonary functions and fibrinogen metabolism in acute pancreatitis. Br J Surg 68:870—873.
11. McMahon MJ, Playforth MJ, Pickford IR (1980) A comparative study of methods for the prediction of severity of attacks of acute pancreatitis. Br J Surg 67:22–25.
12. Ranson JH, Rifkind KM, Roses DF, et al. (1974) Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 139:69–81.
13. Imrie CW (1997) Classification of acute pancreatitis and the role of prognostic factors in assessing severity of disease. Schweiz Med Wochenschr
127:798—804.
14. Imrie CW (2003) Prognostic indicators in acute pancreatitis. Can J Gastroenterol 17:325–328.
15. Knaus WA (2002) APACHE 1978–2001: the development of a quality assurance system based on prognosis: milestones and personal reflections. Arch Surg 137:37–41.
16. Knaus WA, Draper EA, Wagner DP, et al. (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818—829.
17. Buter A, Imrie CW, Carter CR, et al. (2002) Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 89:298–302.
18. Martinez J, Johnson CD, Sanchez-Paya J, et al. (2006) Obesity is a definitive risk factor of severity and mortality in acute pancreatitis: an updated metaanalysis. Pancreatology 6:206-–209.
19. Windsor AC, Kanwar S, Li AG, et al. (1998) Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 42:431–435.
20. Marik PE, Zaloga GP (2004) Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 328:1407–1412.
21. Eatock FC, Chong P, Menezes N, et al. (2005) A randomised study of early nasogastric versus nasojejunal feeding in acute severe pancreatitis. Am J Gastroenterol 100:432–439.
22. Eatock FC, Brombacher GD, Steven A, et al. (2000) Nasogastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol 28:23–29.
23. Isenmann R, Runzi M, Kron M, et al. (2004) Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology 126:997–1004.

Disclaimers

Conflict Of Interest

The Journal requires that authors disclose any potential conflict of interest that they may have. This is clearly stated in the Journal’s published “Guidelines for Authors”. The Journal follows the Guidelines against Conflict of Interest published in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (http://www.icmje.org/urm_full.pdf).

Financial Statement

The authors of this article have not been paid. The Journal is financed by subscriptions and advertising. The Journal does not receive money from any other sources. The decision to accept or refuse this article for publication was free from financial considerations and was solely the responsibility of the Editorial Panel and Editor-in-Chief.

Patient Consent statement

All pictures and investigations shown in this article are shown with the patients’ consent. We require Authors to maintain patients’ anonymity and to obtain consent to report investigations and pictures involving human subjects when anonymity may be compromised. The Journal follows the Guidelines of the Uniform Requirements for Manuscripts (http://www.icmje.org/urm_full.pdf). The Journal requires in its Guidelines for Authors a statement from Authors that “the subject gave informed consent”.

Animal & Human Rights

When reporting experiments on human subjects, the Journal requires authors to indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2008.

About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

The database is fully searchable, or can be browsed by medical specialty. Abstracts can be read free of charge, however a subscription is required in order to read the complete cases.