What Is Acute Pancreatitis?

Acute pancreatitis is an inflammatory response that causes pancreatic enzymes to self-digest, edema, hemorrhage, and even necrosis after pancreatic enzymes are activated in the pancreas. Clinically, it is characterized by acute upper abdominal pain, nausea, vomiting, fever, and increased blood pancreatic enzymes. The severity of the lesions varies. Pancreatic edema is the main cause of the disease, which is more common in the clinic. The condition is often self-limiting and the prognosis is good. It is also called mild acute pancreatitis. A few severe cases of pancreatic hemorrhage and necrosis, often secondary to infection, peritonitis and shock, have a high mortality rate, and are called severe acute pancreatitis. Clinical pathology often divides acute pancreatitis into two types: edema type and hemorrhagic necrosis type.

Basic Information

English name

acute pancreatitis

Visiting department

Emergency Department, Gastroenterology, General Surgery, Hepatobiliary Surgery

Multiple groups

Overeating, those with biliary disease, hyperlipidemia, hypercalcemia, family genetic history

Common causes

Related to excessive drinking, gallstones, biliary infections, etc.

Common symptoms

Abdominal pain, nausea, vomiting, fever, and symptoms such as shock and jaundice

Causes of Acute Pancreatitis

The etiology of this disease is still not very clear. The etiology of pancreatitis is related to excessive drinking and gallstones in the bile ducts.

Obstruction factor

Bile reflux is caused by biliary tapeworms, incarcerated stones in the abdomen, and narrowing of the duodenal papilla. Such as the obstruction of the lower end of the bile duct is obvious, the pressure in the bile duct is very high, the high pressure bile countercurrent to the pancreatic duct, causing the pancreatic acinar rupture, pancreatic enzymes enter the interstitial pancreas and pancreatitis occurs.

2. Alcohol factor

Long-term drinkers are prone to pancreatitis. On this basis, when a large amount of alcohol and overeating are promoted, a large amount of pancreatic enzymes are promoted, causing the pressure in the pancreatic ducts to rise suddenly, causing pancreatic vesicles to rupture and pancreatic enzymes to enter between Interstitial and trigger acute pancreatitis. The simultaneous intake of alcohol and high-protein and high-fat foods not only increases pancreatin secretion, but also causes hyperlipoproteinemia. At this time, pancreatic lipase breaks down triglycerides and releases free fatty acids to damage the pancreas.

3. Vascular factors

Acute pancreatitis caused by small arterial and venous embolism and obstruction of the pancreas, and acute pancreatitis caused by acute blood circulation disorders of the pancreas. Another factor is based on pancreatic duct obstruction. When the pancreatic duct is obstructed, high pressure in the pancreatic duct causes passive pancreatin Sexual "infiltration" interstitial. The stimulation of pancreatic enzymes causes embolism of the lymphatic vessels, veins and arteries in the interstitial area, followed by ischemic necrosis of the pancreas.

4. Trauma

Pancreatic trauma ruptures pancreatic ducts, overflows pancreatic fluid, and inadequate blood supply after trauma, leading to acute severe pancreatitis.

5. Infectious factors

Acute pancreatitis can occur with various bacterial and viral infections. Viruses or bacteria enter the pancreatic tissue through the blood or lymph, causing pancreatitis. In general, these infections are simple edema pancreatitis, and there are fewer cases of hemorrhagic and necrotizing pancreatitis.

6. Metabolic diseases

Can be related to hypercalcemia, hyperlipidemia and other conditions.

7. Other factors

Such as drug allergies, hemochromatosis, heredity and so on.

Clinical manifestations of acute pancreatitis

The main symptoms of acute edema-type pancreatitis are abdominal pain, nausea, vomiting, and fever, while hemorrhagic and necrotizing pancreatitis can occur with shock, high fever, jaundice, abdominal distension and intestinal paralysis, peritoneal irritation, and congestion spots.

General symptoms

(1) Abdominal pain: It is the earliest symptom that often occurs after overeating or extreme fatigue. Most of them are sudden attacks, located in the middle of the upper abdomen or to the left. Pain is a progressive and exacerbating pain. The pain radiates to the back and flank. In the case of hemorrhagic and necrotizing pancreatitis, a short period of time after the onset is total abdominal pain, sharp abdominal distension, and at the same time, shocks of varying severity appear.

(2) Nausea and vomiting: Frequent attacks, initially enter food bile-like substances, progressively worsen the condition, and soon enter intestinal paralysis, then the excretions are fecal samples.

(3) Jaundice: Acute edema pancreatitis occurs less frequently, accounting for about 1/4. It is more common in acute hemorrhagic pancreatitis.

(4) Dehydration: Dehydration in acute pancreatitis is mainly caused by intestinal paralysis and vomiting, while severe pancreatitis can cause severe dehydration and electrolyte disturbance in a short period of time. Hemorrhagic and necrotizing pancreatitis, severe dehydration can occur within hours to 10 hours after the onset of the disease, without anuria or oliguria.

(5) Due to a large number of inflammatory exudations of the pancreas, necrosis of the pancreas and localized abscesses may lead to varying degrees of body temperature elevation. In the case of mild pancreatitis, the general body temperature is within 39 ° C, and it can drop in 3 to 5 days. For severe pancreatitis, body temperature is usually 39 to 40 ° C, delirium often occurs, persists for several weeks, and the symptoms of toxemia occur.

(6) A few hemorrhagic and necrotizing pancreatitis, pancreatic juice and even necrotic and dissolved tissues reach the skin along the tissue gap and dissolve subcutaneous fat, which ruptures the capillaries and bleeds, making the local skin blue-purple, and some can melt into large pieces In the lower anterior abdominal wall, it can also appear around the umbilicus.

(7) The location of the pancreas is deep. General mild edema pancreatitis has tenderness deep in the upper abdomen, and a few have tenderness in the anterior abdominal wall. For acute severe pancreatitis, due to its large amount of pancreatic dissolution, necrosis, and bleeding, the front and back peritoneum are involved, the whole abdominal muscles are tight, tender, and the whole abdomen is flatulent, and there may be a large amount of inflammatory ascites, and mobile dullness may occur. . Bowel sounds disappeared and paralytic intestinal obstruction appeared.

(8) Due to the inflammatory stimulus of exudate, pleural effusion may occur, which is more common on the left side, which can cause atelectasis on the same side and dyspnea.

(9) A large amount of necrotic tissue accumulates in the small omental sac. A raised mass can be seen in the upper abdomen, which is tender when touched, and the boundary of the mass is often unclear. A few patients have no obvious signs of abdominal tenderness, but still have high fever, increased white blood cell count, and often appear like "partial intestinal obstruction".

2. Local complications

(1) Pancreatic abscess: It usually appears 2 to 3 weeks after the onset of disease. At this time, the patient had high fever with symptoms of poisoning, increased abdominal pain, palpable upper abdominal mass, and a significant increase in white blood cell count. The puncture solution is purulent, and there is bacterial growth in culture.

(2) Pseudocysts of the pancreas: most often formed 3 to 4 weeks after the onset of disease. Physical examination can often affect the upper abdominal mass, and large cysts can compress adjacent tissues to produce corresponding symptoms.

3. Systemic complications

There are often complications such as acute respiratory failure, acute renal failure, heart failure, gastrointestinal bleeding, pancreatic encephalopathy, sepsis and fungal infections, and hyperglycemia.

Acute pancreatitis examination

Blood routine

Many white blood cell counts increased and the neutrophil nucleus shifted to the left.

2. Determination of hematuria amylase

Serum (pancreatic) amylase begins to increase 6-12 hours after the onset, and begins to decrease 48 hours, and lasts 3 to 5 days. The serum amylase is three times more than the normal value, which can be diagnosed as the disease.

3. Determination of serum lipase

Serum lipase usually rises from 24 to 72 hours after the onset, and lasts for 7 to 10 days. It has diagnostic value for patients with acute pancreatitis who have a late diagnosis after the disease, and also has high specificity.

4. Ratio of amylase endogenous creatinine clearance

In acute pancreatitis, due to the increase of vasoactive substances, the glomerular permeability is increased, the renal clearance of amylase is increased, and the clearance of creatinine remains unchanged.

5. serum ferritin

When hemorrhage occurs in the abdominal cavity, the red blood cells are destroyed to release heme, which can be changed into heme by the action of fatty acids and elastin, which is combined with albumin to form methaemoglobin, which is often positive in the onset of severe pancreatitis.

6. Biochemical inspection

Temporary blood glucose elevation and persistent fasting blood glucose above 10 mmol / L reflect pancreatic necrosis, suggesting a poor prognosis. Hyperbilirubinemia can be seen in a small number of clinical patients, more than 4 to 7 days after the onset to return to normal.

7.X-ray abdominal plain film

Can exclude other acute abdominal diseases, such as visceral perforation, "sentinel pimple" and "colonectomy sign" are indirect indications of pancreatitis, diffuse blurred shadow psoas muscle borders suggest the presence of peritoneal effusion, intestinal paralysis Or paralytic intestinal obstruction.

8. Abdominal ultrasound

It should be used as a routine preliminary screening test. Ultrasonography of acute pancreatitis can show pancreatic enlargement, abnormal echo in and around the pancreas; also understand the gallbladder and biliary tract; late stage has diagnostic significance for abscesses and pseudocysts, but it is often affected by abdominal distension. Its observation.

9.CT imaging

Provides assistance for organ involvement near the severity of acute pancreatitis.

Differential diagnosis of acute pancreatitis

Acute pancreatitis should be distinguished from the following diseases:

Acute peptic ulcer

There is a more typical history of ulcers. Abdominal pain suddenly aggravates, abdominal muscles are tense, liver dullness disappears, and X-ray fluoroscopy shows that there is free gas under the diaphragm, which can be identified.

2. Cholelithiasis and acute cholecystitis

He has a history of biliary colic, the pain is located in the right upper abdomen, and often radiates to the right shoulder. Murphy's sign is positive, blood and urinary amylase are slightly elevated, and B-ultrasound and X-ray biliary angiography can confirm the diagnosis.

3. Acute intestinal obstruction

Abdominal pain is paroxysmal, bloating, vomiting, hyperactive bowel sounds, air over water, no exhaust, visible bowel type, abdominal liquid X-ray visible liquid-gas level.

4. Myocardial infarction

With a history of coronary heart disease, sudden onset, sometimes pain is limited to the upper abdomen, ECG images show myocardial infarction, serum myocardial enzymes are elevated, and hematuria amylase is normal.

Acute pancreatitis treatment

Non-surgical treatment

Prevention and treatment of shock, improvement of microcirculation, spasmolysis, analgesia, inhibition of pancreatic enzyme secretion, anti-infection, nutritional support, prevention of complications, and some measures to strengthen intensive care.

(1) Preventing shock and improving microcirculation Actively supplement liquids, electrolytes, and heat to maintain circulation stability and water-electrolyte balance.

(2) Inhibition of pancreatic secretion H ₂ receptor blocker; aprotinin; 5-fluorouracil; fasting and gastrointestinal decompression.

(3) Antispasmodic and analgesic Analgesics should be given regularly. The traditional method is intravenous infusion of 0.1% procaine for vein closure. It can also be used with dulodine and atropine at regular intervals to both relieve pain and relieve Oddi sphincter spasm and disable morphine to avoid causing Oddi sphincter spasm. In addition, isoamyl nitrite, glyceryl nitrite, etc. are used in severe pain, especially in older patients, which can relieve the spasm of the Oddi sphincter to a certain extent, and it is also very good for coronary blood supply.

(4) Nutritional support During acute severe pancreatitis, the body has high catabolism, inflammatory exudation, long-term fasting, high fever, etc. The patient is in a negative nitrogen balance and hypoproteinemia, so nutritional support is needed, and nutritional support is being given. At the same time, the pancreas should not be secreted or less secreted.

(5) Application of antibiotics In patients with AP, intravenous antibiotics are not recommended to prevent infection. For some susceptible people (such as biliary obstruction, old age, low immunity, etc.), intestinal bacterial translocation may occur, quinolones, cephalosporins, carbapenems, and metronidazole can be selected to prevent infection.

(6) Peritoneal lavage For those who have a large amount of exudation in the abdominal cavity, peritoneal lavage can be performed to dilute and exclude the liquid containing a large amount of pancreatin and toxin substances in the abdominal cavity.

(7) Strengthen supervision.

(8) Indirect cooling therapy.

2. Surgical treatment

Although there are localized regional pancreatic necrosis and exudation, if there is no infection and the symptoms of systemic poisoning are not very serious, there is no need to rush to surgery. If there is infection, it should be treated accordingly.

Prognosis of acute pancreatitis

The fatality rate of acute pancreatitis is about 10%, and almost all deaths are first episodes. The presence of respiratory insufficiency or hypocalcemia indicates a poor prognosis. The fatality rate of severe necrotizing pancreatitis is 50% or higher, which can be reduced to about 20% by surgery.