Acute pancreatitis is an acute inflammatory disease in which damage to pancreatic gland cells occurs due to various causes such as gallstones, alcohol, metabolic disorders, drugs, and abdominal damage, resulting in extensive interstitial edema and bleeding.
Abdominal pain is the most important clinical symptom in acute pancreatitis, and its severity varies from mild pain to severe intolerable pain. The stabbing pain is persistent and often radiates from the upper abdomen or around the navel to the back or left flank. Because the pain worsens when lying down, the patient usually takes a position with the back bent forward and the knee pulled. Abdominal pain is usually aggravated by food intake, and is often accompanied by nausea and vomiting.
Symptoms of acute pancreatitis on physical examination include tachycardia (pulse more than 100 beats) and mild fever, and in severe cases, hypotension and shock. Jaundice may appear when gallstones are the cause or when pancreatic edema is severe, but it is not a common sign of pancreatitis.
The most frequent causes are gallstones and alcohol, accounting for 60-80% of acute pancreatitis. Pancreatitis caused by gallstones accounts for 30~75% of the causes of acute pancreatitis, and when gallstones enter and become lodged in the sphincter of Oddi, the distal end of the biliary-pancreatic duct, or when gallstones are discharged through the biliary-pancreatic duct If the sphincter is dysfunctional, pancreatitis may occur. Alcohol accounts for 30% to 60% of cases of acute pancreatitis. Chronic drinkers may have mild impairment in pancreatic secretory function even without a history of pancreatitis. Therefore, when alcohol-related pancreatitis is first detected in chronic drinkers, it is often chronic rather than acute.
Other causes include surgery, endoscopic retrograde cholangiopancreatography (ERCP), hypertriglyceridemia, hyperparathyroidism and hypercalcemia, infection by parasites or viruses, trauma, and tumors. Idiopathic pancreatitis refers to a case in which a specific pathogenesis exists but cannot be identified by existing knowledge or diagnostic methods. Most of pancreatitis classified as idiopathic in the past was found to be due to causes such as micro gallstones, Oddi sphincter dysfunction, and split pancreas.
Acute pancreatitis can be easily diagnosed in most cases through characteristic clinical features, serum biochemical tests, and radiological tests. However, acute pancreatitis can have various features, ranging from a mild clinical course to a severe course. That is, from edema pancreatitis, which can be recovered within a few days only with conservative treatment, to pancreatic necrosis, lung damage, and multiple organ failure in which the organs of the body do not function properly, necrosis with a mortality rate of about 30%. The clinical course varies from pancreatitis to pancreatitis.
For the diagnosis of acute pancreatitis, it is necessary to prove that the concentration of pancreatic digestive enzymes in the blood is increased.
Among pancreatic digestive enzymes, amylase and lipase are the most widely used for diagnosing pancreatitis. Acute pancreatitis can be confirmed if the serum amylase concentration is more than 3 times the normal value and there is characteristic abdominal pain, and there are no other causes such as salivary gland disease or perforation of the digestive tract. However, the level of amylase starts to increase 2 to 12 hours after the onset of symptoms, and the half-life in the blood to halve the level is about 10 hours. decreased to a normal level within Therefore, the concentration of serum amylase is not correlated with the severity of pancreatitis, but caution is required because serum amylase does not increase or return to normal when pancreatic pseudocyst (inflammatory cystic disease caused by leakage of pancreatic juice) or necrosis occurs.
In the case of lipase, it begins to increase 4 to 8 hours after the onset of symptoms, usually reaches a maximum concentration after 24 hours, and is normalized after 8 to 14 days. Therefore, in the diagnosis of acute pancreatitis, the sensitivity and specificity are higher than that of amylase. Recently, the urine trypsinogen-2 test method is attracting attention as a simple test method with high sensitivity and specificity.
When acute pancreatitis is clinically suspected, various imaging modalities are performed to determine the pancreatic condition, whether it is accompanied by complications, and to identify the cause and differential diagnosis. Abdominal radiography and chest radiography are used to diagnose complications such as intestinal paralysis due to pancreatitis, pleural fluid and atelectasis (the loss of air in the alveoli of the whole or part of the lung), and to differentiate diseases such as intestinal perforation important for diagnosis. Abdominal ultrasonography is useful for diagnosing pancreatic echo (wavelength) decreased due to edema in pancreatitis, swelling of the pancreas, fluid retention around the pancreas, and the presence or absence of cysts. Ultrasonography is also useful in diagnosing pancreatitis because it can detect the presence of gallstones. However, due to abdominal obesity or intestinal paralysis, which may accompany pancreatitis, air in the intestine increases, interfering with pancreatic examination.
Abdominal computed tomography (CT) can confirm the status of the pancreas and surrounding organs, the presence or absence of pancreatic necrosis, and pathological changes in the pancreas and retroperitoneum in acute pancreatitis. It is useful for diagnosing pancreatitis and complications because it can detect changes in tissues and tissues.
In addition, various blood tests such as general blood test, blood sugar test, electrolyte test, and arterial blood test are performed to determine the severity of acute pancreatitis and predict future course and treatment results.
About 80% of acute pancreatitis have a mild clinical course of edematous pancreatitis that recovers completely within a few days without complications, but about 20% show severe pancreatitis.
In the case of mild pancreatitis, it recovers naturally through pain treatment and active fluid therapy, and when the abdominal pain disappears after a period of fasting for several days, food intake is possible even in the early stages of the disease. On the other hand, severe pancreatitis may be accompanied by multiple organ failure such as shock, hypoxia, and renal function decline, or complications such as pancreatic necrosis may occur. Therefore, it is very important to maintain circulating blood flow, to prevent and treat secondary infection when local complications are accompanied, and to consider antibiotic administration and appropriate surgical treatment. This treatment process can usually take from several weeks to several months, and in many cases, the patient is unable to eat orally for a long period of time.
Recently, it has been reported that effective antagonism (offset of the action of a specific factor through the opposite action) of related factors according to the principle of occurrence of pancreatitis has a therapeutic effect, and various protease inhibitors and anti-inflammatory cytokines are clinically It is being used in therapy, and more effective therapeutic drugs are being developed.
Progress and complications
Most cases of acute pancreatitis are cured without complications, but about 25% of cases progress to severe complications and complications occur. In this case, the mortality rate is 2~22%. 60% of deaths occur within 1 week of hospitalization, and the main cause of death in this case is respiratory dysfunction.
40% of them die after one week of hospitalization, and the main cause is sepsis, in which the toxin of bacteria spreads into the blood and the organs of the body lose their functions. According to a recent report, complications occur in about 27% of all patients, and complications include atelectasis (6.5%), pleural fluid (6.8%), cellulitis (4.2%), pseudocyst (3.3%), shock, abscess, ascites. , gastrointestinal bleeding, sepsis, and acute renal failure.
Moderate pancreatitis is classified as severe acute pancreatitis when one or more signs of pancreatic local complications or systemic complications such as acute renal failure, hypotension, respiratory dysfunction, and blood coagulation disorders are present. Otherwise, it is classified as mild. Local complications of acute pancreatitis include acute fluid collection, pseudocyst of the pancreas, pancreatic abscess, pancreatic necrosis, and bile duct obstruction.
The most common cause of acute pancreatitis is alcohol and gallstones. Excessive drinking should be avoided to prevent acute pancreatitis. In addition, if gallstones are asymptomatic, no special treatment is required, but if they cause symptoms, surgical treatment to remove the gallbladder should be considered.
(Next post will be updated soon.)