Pancreatitis

Pancreatitis is difficult to diagnose partially due to the location of the pain and the nonspecific signs & symptoms
Exocrine and endocrine functions of the pancreas

  • Exocrine:
    • Secretes 1-2 L/day of alkaline fluid (pH = 8.3)
      • Consists of bicarb, water, Na/K/Cl/Ca/Mg/Zn/PO4/SO4, digestive enzymes
    • Primary Digestive enzymes:  amylase, lipase, proteolytic enzymes (for trypsin, chymotrypsin)
    • Autoregulation:  pancreas secretes bicarb in response to secretin.  Pancreas releases amylase, lipase, etc in response to cholecystokinin
  • Endocrine:
    • Contain islets of langergans (B-islet cells) which secretes insulin, glucagon, somatostatin, polypeptide hormones

Acute and chronic pancreatitis:

  • Acute pancreatitis:   (reversible disease, majority of patients recover in 3-5 days)
    • Causes:  40% are alcohol related, 30-85% biliary tract disease, inflammatory component (neutrophils flood pancreas), proteolytic enzymes get prematurely activated
      • Either toxins (EtOH), mechanical obstruction (due to gall stones, trauma, tumors, etc), infection (HIV, hepatitis, mumps, etc), metabolic abnormalities (hypertriglyceridemia, hypercalcemia), or drug-induced (corticosteroids, estrogens, lasix, opiates, bactrim, valproic acid)
    • Signs & symptoms:  sudden, severe, knife-like abdominal pain & distention, N/V, low-grade fever, hypotension, pain radiates to back
    • Diagnostic tests and procedures:
      • Serum amylase:  peaks w/in 24 hours (3x greater than normal), nonspecific test
      • Serum lipase:  more specific to pancreatitis, peaks w/ amylase but lasts longer
      • Contrast-enhanced computed tomography (CECT–gold standard), Abdominal x-ray, ultrasound, ERCP (for gallstone pancreatitis), MRCP
  • Chronic pancreatitis:  (deterioration of pancreas function w/ alcohol abuse, causes death in 20-25 years)
    • Causes:  70% alcohol related, also could be due to functional or structural damage (obstruction-tumors), chronic hypercalcemia, CF
    • Signs & symptoms:  dull, constant pain which is unresponsive to meds, malabsorption of fats (causes steatorrhea in stool & weight loss), azotorrhea (loss of protein in stool), diabetes
    • Diagnostic tests and procedures:  diagnosis is based on classic triad–calcification, diabetes, steatorrhea (fat in stool), ERCP still gold standard of imaging, allows determination if surgery is needed

Therapeutic options for treating a patient with pancreatitis

  • Acute pancreatitis treatment:  majority of patients recover in 3-5 days
    • Replace fluids & electrolyte losses
    • Use enteral vs. parenteral nutrition (reduce autodigestion)
    • Pain control (use meperidine vs. other opioids b/c it doesn’t cause a spasm of the sphincter of oddi)
    • H2RAs
  • Chronic pancreatitis treatment:  (goal is to relieve pain, prevent complications & correct maldigestion)
    • Quit drinking EtOH
    • Pain control:  NSAIDs, APAP, tramadol (don’t use opioids like in acute pancreatitis)
    • Nutritional changes:  avoid EtOH & implement low-fat diet
    • May admin exogenous pancreatic enzymes (lipase, amylase, protease, etc)
      • **starting dose:  30,000 IU lipase & 10,000 IU trypsin w/ each meal/snack**
        • Names of meds correlate to lipase content:
          • Creon-20 = 20,000 units lipase/capsule
          • Ultrase MT 18 = 18,000 units lipase/capsule
        • There are no longer any products w/ more than 20,000 units on the market
      • For pain control use the non-enteric coated tablets
      • For steatorrhea use enteric coated tablets
    • Antacids (no Ca or Mg) & H2RAs

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