16-02-2013, 04:06 PM
Chronic pancreatitis
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Introduction
Chronic pancreatitis is a progressive inflammatory and fibrotic disease of the pancreas with hallmark features of abdominal pain, malabsorption, malnutrition, diabetes mellitus, and pancreatic calcifications. Currently, there is no definitive medical treatment for pancreatic inflammation, fibrosis, or pain. In this review, we focus on
environmental risk factors, natural history, coexistent alcoholic chronic pancreatitis and cirrhosis, asymptomatic pancreatic hyperenzymemia, diagnosis, pancreatic calcifications, pancreatic function testing, and treatment of exocrine pancreatic insufficiency (EPI) and pain. Traditionally, chronic pancreatitis has been classed as fundamentally
different from acute pancreatitis the latter is usually characterised by
restoration of normal pancreatic histology after full clinical
recovery. However, acute, recurrent acute, and chronic pancreatitis are now regarded as a disease continuum.There are several reasons for this change: recurrent acute pancreatitis can develop into chronic pancreatitis; there is an overlap in causative factors, both genetic and environmental; experimental protocols can be modifi ed to induce each
condition;and the pancreatitis attack is stereotyped patients have severe abdominal pain and increased blood amylase, lipase, and trypsinogen.
Pancreatitis
Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenum the first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bile a liquid produced in the liver and stored in the gallbladder to digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy. Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the
pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them. Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur. Both forms of pancreatitis occur more often in men than women.
Acute pancreatitis
Acute pancreatitis is inflammation of the pancreas that occurs suddenly and usually resolves in a few days with treatment. Acute pancreatitis can be a life-threatening illness with severe complications . Each year, about 210,000 people in the United States are admitted to the hospital with acute pancreatitis. The most common cause of acute pancreatitis is the presence of gallstones small, pebble-like substances made of hardened bile that cause inflammation in the pancreas as they pass through the common bile duct. Chronic, heavy alcohol use is also a common cause. Acute pancreatitis can occur within hours or as long as 2 days after consuming alcohol Other causes of acute pancreatitis include abdominal trauma, medications, infections, tumors, and genetic abnormalities of the pancreas.
Symptoms
Acute pancreatitis usually begins with gradual or sudden pain in the upper abdomen that sometimes extends through the back. The pain may be mild at first and feel worse after eating. But the pain is often Severe and may become constant and last for several days.
A person with acute pancreatitis usually looks and feels very ill and needs immediate medical attention.
Other symptoms may include:-
• a swollen and tender abdomen
• nausea and vomiting
• fever
• a rapid pulse
Severe acute pancreatitis may cause dehydration and low blood pressure. The heart, lungs, or kidneys can fail. If bleeding occurs in the pancreas, shock and even death may follow.
Diagnosis
While asking about a person’s medical history and conducting a thorough physical examination, the doctor will order a blood test to assist in the diagnosis . During acute pancreatitis, the blood contains at least three times the normal amount of amylase and lipase, digestive enzymes formed in the pancreas.
Changes may also occur in other body chemicals such as glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the person’s condition improves, the levels usually return to normal.
Diagnosing acute pancreatitis is often difficult because of the deep location of the pancreas.
Treatment
Treatment for acute pancreatitis requires a few days’ stay in the hospital for intravenous (IV) fluids, antibiotics, and medication to relieve pain. The person cannot eat or drink so the pancreas can rest. If vomiting occurs, a tube may be placed through the nose and into the stomach to remove fluid and air. Unless complications arise, acute pancreatitis usually resolves in a few days. In severe cases, the person may require nasogastric feeding—a special liquid given in a long, thin tube inserted through the nose and throat and into the stomach—for several weeks while the pancreas heals. Before leaving the hospital, the person will be advised not to smoke, drink alcoholic beverages, or eat fatty meals. In some cases, the cause of the pancreatitis is clear, but in others, more tests are needed after the person is discharged and the pancreas is healed.
Complications
Gallstones that cause acute pancreatitis require surgical removal of the stones and the gallbladder. If the pancreatitis is mild, gallbladder removal—called cholecystectomy may proceed while the person is in the hospital . If the pancreatitis is severe, gallstones may be removed using therapeutic endoscopic retrograde cholangiopancreatography (ERCP) a specialized technique used to view the pancreas, gallbladder, and bile ducts and treat complications of acute and chronic pancreatitis. Cholecystectomy is delayed for a month or more to allow for full recovery. For more information, see the Gallstones fact sheet from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). If an infection develops, ERCP or surgery may be needed to drain the infected area, also called an abscess. Exploratory surgery may also be necessary to find the source of any bleeding, to rule out conditions that resemble pancreatitis, or to remove severely damaged pancreatic tissue. Pseudocysts accumulations of fluid and
tissue debris—that may develop in the pancreas can be drained using ERCP or EUS. If pseudocysts are left untreated, enzymes and toxins can enter the bloodstream and affect the heart, lungs, kidneys, or other
organs. Acute pancreatitis sometimes causes kidney failure. People with kidney failure need blood-cleansing treatments called dialysis or a kidney transplant. In rare cases, acute pancreatitis can cause
breathing problems. Hypoxia, a condition that occurs when body cells and tissues do not get enough oxygen, can develop. Doctors treat hypoxia by giving oxygen to the patient. Some people still experience lung failure even with oxygen and require a respirator for a while to help them breathe.
Chronic pancreatitis
Chronic pancreatitis is inflammation of the pancreas that does not heal or improve—it gets worse over time and leads to permanent damage. Chronic pancreatitis, like acute pancreatitis, occurs when digestive enzymes attack the pancreas and nearby tissues, causing episodes of pain. Chronic pancreatitis often develops in people who are between the ages of 30 and 40.
The most common cause of chronic pancreatitis is many years of heavy alcohol use. The chronic form of pancreatitis can be triggered by one acute attack that damages the pancreatic duct.
The damaged duct causes the pancreas to become inflamed. Scar tissue develops and the pancreas is slowly destroyed.
Other causes of chronic pancreatitis are
• hereditary disorders of the pancreas
• cystic fibrosis the most common
inherited disorder leading to chronic
pancreatitis
• hypercalcemia high levels of calcium
in the blood
• hyperlipidemia or hypertriglyceridemia
high levels of blood fats
• some medicines
• certain autoimmune conditions
• unknown causes
• hereditary disorders of the pancreas
• cystic fibrosis the most common
inherited disorder leading to chronic
pancreatitis
• hypercalcemia high levels of calcium
in the blood
• hyperlipidemia or hypertriglyceridemia
high levels of blood fats
• some medicines
• certain autoimmune conditions
• unknown causes