Pancreatitis

Pancreas[1]

Pancreatitis Main Page

Patient Information

Overview

Causes

Classification

Acute Pancreatitis
Chronic Pancreatitis
Hereditary Pancreatitis
Autoimmune Pancreatitis

Differential Diagnosis

For patient information, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: ; Iqra Qamar M.D.[2]

## Overview[edit | edit source]

Pancreatitis is an inflammatory disease of the pancreas characterized by reversible or irreversible changes in pancreatic structure and function leading to inflammation and fibrosis. The concept of pancreas and pancreatic duct was first described by Johannes Wirsung of Padua in 1642. Pancreatitis may be classified as acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, and hereditary pancreatitis. Common causes of pancreatitis may include gallstones, hypertriglyceridemia, alcohol, drugs, genetic, autoimmune, iatrogenic, trauma, infection, surgical causes, and obstruction. Acute pancreatitis usually presents with fever, sharp abdominal pain, nausea and vomiting. Patients with chronic pancreatitis present with dull abdominal pain, steatorrhea, pancreatic diabetes, nausea, weight loss, pseudocyst and pancreatic cancer.

## Causes[edit | edit source]

Type of pancreatitis  | Causes

|

Acute pancreatitis |

* Gallstones
* Hypertriglyceridemia
* Alcohol
* Drugs
* Genetic
* Autoimmune
* Iatrogenic
* Trauma
* Infection
* Surgical
* Obstruction

Chronic pancreatitis |

* Alcoholic
* Tobacco smoking
* Hypercalcemia
* Hyperlipidemia
* Chronic renal failure
* Medications—phenacetin abuse
* Toxins—organotin compounds (e.g. dibutylin dichloride, DBTC)
* Idiopathic
* Tropical
* Genetic
* Autoimmune
* Radiation
* Obstruction

Autoimmune pancreatitis |

* Idiopathic
* Systemic autoimmune conditions

Hereditary pancreatitis |

* Genetic mutations

## Classification[edit | edit source]

Pancreatitis may be classified as:

* Acute pancreatitis
* Chronic pancreatitis
* Autoimmune pancreatitis
* Hereditary pancreatitis

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| Acute pancreatitis|

| Chronic pancreatitis|

| Autoimmune pancreatitis|

| Hereditary pancreatitis|

## Differential Diagnosis[edit | edit source]

##### Differentiating pancreatitis from other diseases on the basis of abdominal pain and weight loss:[edit | edit source]

Pancreatitis presents most commonly with abdominal pain. Pancreatitis must be differentiated from various disease which present with abdominal pain and weight loss such as peptic ulcer disease, pancreatic carcinoma, gastritis, and inflammatory bowel disease.

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

| Disease  | Clinical manifestations | Diagnosis  | Comments

|
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Symptoms | Signs
Abdominal Pain  | Fever  | Rigors and chills  | Nausea or vomiting  | Jaundice  | Constipation  | Diarrhea  | Weight loss  | GI bleeding  | Hypo-

tension

| Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging
Chronic pancreatitis | Epigastric | −  | −  | ±  | ±  | −  | \+  | \+  | −  | −  | −  | −  | N  |

* Increased amylase / lipase
* Increased stool fat content
* Pancreatic function test

| CT scan

* Calcification
* Pseudocyst
* Dilation of main pancreatic duct

* Predisposes to pancreatic cancer

Pancreatic carcinoma | Epigastric | −  | −  | \+  | \+  | −  | \+  | \+  | −  | −  | −  | −  | N  |

* ↑ Alkaline phosphatase
* ↑ serum bilirubin
* ↑ gamma-glutamyl transpeptidase
* ↑ CA 19-9

* MDCT with  PET/CT
* MRI

Skin manifestations may include:

* Bullous pemphigoid
* Cicatricial pemphigoid
* Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
* Pancreatic panniculitis

Peptic ulcer disease | Diffuse  | ±  | −  | \+  | −  | −  | −  | \+  |

* Gastric ulcer- melena and hematemesis
* Duodenal ulcer- melena and hematochezia

| Positive if perforated  | Positive if perforated  | Positive if perforated  | N  |

* Ascitic fluid
* LDH > serum LDH
* Glucose < 50mg/dl
* Total protein > 1g/dl

* Air under diaphragm in upright CXR

* Upper GI endoscopy for diagnosis

Disease  | Abdominal Pain  | Fever  | Rigors and chills  | Nausea or vomiting  | Jaundice  | Constipation  | Diarrhea  | Weight loss  | GI bleeding  | Hypo-

tension

| Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging  | Comments
Gastritis | Epigastric | ±  | −  | \+  | −  | −  | −  | Positive in chronic gastritis  | \+  | −  | −  | −  | N  |

* H.pylori infection diagnostic tests

* Endoscopy

* H.pylori gastritis guideline recommendation

Gastric outlet obstruction | Epigastric | −  | −  | ±  | −  | −  | −  | \+  | −  | −  | −  | −  | Hyperactive  |

* Complete blood count
* Basic metabolic panel

* Abdominal x-ray\- air fluid level
* Barium upper GI studies- narrowed pylorus

* Succussion splash

Gastroparesis  | Epigastric  | −  | −  | \+  | −  | −  | −  | \+  | −  | ±  | −  | −  | Hyperactive/hypoactive  |

* Hemoglobin
* Fasting plasma glucose
* Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
* HbA1c

* Scintigraphic gastric emptying

* Succussion splash
* Single photon emission computed tomography (SPECT)
* Full thickness gastric and small intestinal biopsy

Dumping syndrome | Lower and then diffuse  | −  | −  | \+  | −  | −  | \+  | \+  | −  | \+  | −  | −  | Hyperactive  |

* Glucose challenge test
* Hydrogen breath test

* Upper GI series
* Gastric emptying study

* Postgastrectomy

Disease  | Abdominal Pain  | Fever  | Rigors and chills  | Nausea or vomiting  | Jaundice  | Constipation  | Diarrhea  | Weight loss  | GI bleeding  | Hypo-

tension

| Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging  | Comments
Inflammatory bowel disease | Diffuse  | ±  | −  | −  | ±  | −  | \+  | \+  | \+  | −  | −  | −  | Normal or hyperactive  |

* Anti-neutrophil cytoplasmic antibody (P-ANCA) in Ulcerative colitis
* Anti saccharomyces cerevisiae antibodies (ASCA) in Crohn's disease

* String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

* Uveitis
* Arthritis

Irritable bowel syndrome | Diffuse  | −  | −  | −  | −  | ±  | ±  | \+  | −  | −  | −  | −  | N  | Normal  | Normal  | Symptomatic treatment

* High dietary fiber

* Osmotic laxatives
* Antispasmodic drugs

Whipple's disease | Diffuse  | ±  | −  | −  | ±  | −  | \+  | \+  | −  | ±  | −  | −  | N  |

* Thrombocytopenia
* Hypoalbuminemia
* Small intestinal biopsy for Tropheryma whipplei

| Endoscopy is used to confirm diagnosis.

Images used to find complications

* Chest and joint x-ray
* CT
* MRI
* Echocardiography

| Extra intestinal findings:

* Uveitis
* Endocarditis
* Encephalitis
* Dementia
* Hepatosplenomegaly
* Arthritis
* Ascites

Disease  | Abdominal Pain  | Fever  | Rigors and chills  | Nausea or vomiting  | Jaundice  | Constipation  | Diarrhea  | Weight loss  | GI bleeding  | Hypo-

tension

| Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging  | Comments
Tropical sprue | Diffuse  | \+  | −  | −  | −  | −  | \+  | \+  | −  | −  | −  | −  | N  |

* Fat soluble vitamin deficiency
* Hypoalbuminemia
* Fecal stool test

| Barium studies:

* Dilation and edema of mucosal folds

* Steatorrhea\- 10-40 g/day (Normal=5 g/day)

Celiac disease | Diffuse  | −  | −  | −  | −  | −  | \+  | \+  | −  | −  | −  | −  | Hyperactive  |

* IgA endomysial antibody
* IgA tissue transglutaminase antibody
* Anti-gliadin antibody
* Small bowel biopsy

| US:

* Bull’s eye or target pattern
* Pseudokidney sign

* Gluten allergy

Colon carcinoma  | Diffuse/localized  | −  | −  | −  | −  | ±  | ±  | \+  | \+  | ±  | −  | −  |

* Normal or hyperactive if obstruction present

* CBC
* Carcinoembryonic antigen (CEA)

* Colonoscopy
* Flexible sigmoidoscopy
* Barium enema
* CT colonography

* PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction

Viral hepatitis | RUQ | \+  | −  | \+  | \+  | −  | Positive in Hep A and E  | \+  | −  | Positive in fulminant hepatitis  | Positive in acute  | \+  | N  |

* Abnormal LFTs
* Viral serology

* US

* Hep A and E have fecal-oral route of transmission
* Hep B and C transmits via blood transfusion and sexual contact.

Liver abscess | RUQ  | \+  | \+  | \+  | \+  | −  | ±  | \+  | −  | \+  | \+  | ±  | Normal or hypoactive  |

* CBC
* Blood cultures
* Abnormal liver function tests

* US
* CT

Hepatocellular carcinoma/Metastasis  | RUQ  | \+  | −  | −  | \+  | −  | −  | \+  | −  | −  | −  | −  |

* Normal
* Hyperactive if obstruction present

* High levels of AFP in serum
* Abnormal liver function tests

* US
* CT
* Liver biopsy

Other symptoms:

* Splenomegaly
* Variceal bleeding
* Ascites
* Spider nevi
* Asterixis

Disease  | Abdominal Pain  | Fever  | Rigors and chills  | Nausea or vomiting  | Jaundice  | Constipation  | Diarrhea  | Weight loss  | GI bleeding  | Hypo-

tension

| Guarding  | Rebound Tenderness  | Bowel sounds  | Lab Findings  | Imaging  | Comments
Cirrhosis | RUQ | −  | −  | −  | \+  | −  | −  | \+  | \+  | \+  | −  | −  | N  |

* Hypoalbuminemia
* Prolonged PT
* Abnormal LFTs
* Hyponatremia
* Thrombocytopenia

| US

* Nodular, shrunken liver
* Ascites

* Stigmata of liver disease
* Cruveilhier- Baumgarten murmur

Small bowel obstruction  | Diffuse  | \+  | −  | \+  | −  | \+  | −  | \+  | −  | \+  | \+  | ±  | Hyperactive then absent  |

* Leukocytosis with left shift indicates complications

| Abdominal X ray

* Dilated loops of bowel with air fluid levels
* Gasless abdomen

* "Target sign"– , indicative of intussusception
* Venous cut-off sign" – suggests thrombosis

Mesenteric ischemia | Periumbilical  | Positive if bowel becomes gangrenous  | −  | \+  | −  | −  | \+  | \+  | \+  | Positive if bowel becomes gangrenous  | Positive if bowel becomes gangrenous  | −  | Hyperactive to absent  |

* Leukocytosis and lactic acidosis
* Amylase levels
* D-dimer

| CT angiography

* SMA or SMV thrombosis

* Also known as abdominal angina that worsens with eating

Acute ischemic colitis | Diffuse  | \+  | ±  | \+  | −  | −  | \+  | \+  | \+  | \+  | \+  | \+  | Hyperactive then absent  |

* Leukocytosis

| Abdominal x-ray

* Distension and pneumatosis

CT scan

* Double halo appearance, thumbprinting
* Thickening of bowel

* May lead to shock

Ruptured abdominal aortic aneurysm | Diffuse  | ±  | −  | \+  | −  | −  | −  | \+  | \+  | \+  | −  | −  | N  |

* Fibrinogen
* D-dimer

* Focused Assessment with Sonography in Trauma (FAST)

* Unstable hemodynamics

Pleural empyema | RUQ/Epigastric | \+  | ±  | −  | −  | −  | −  | \+  | −  | −  | −  | −  | N  |

* Thoracentesis

| Chest X-ray

* Pleural opacity

* Localization of effusion

| Physical examination

* Crackles
* Egophony
* Increased tactile fremitus

Template:WikiDoc Sources

1. ↑ <https://en.wikipedia.org/wiki/Pancreas#/media/File:Blausen_0699_PancreasAnatomy2.png>