Acute Pancreatitis

This is a medical emergency marked by acute abdominal stress. Symptoms are caused by spillage of pancreatic fluids into the abdominal cavity. These fluids contain enzymes which begin to digest and destroy the lining of the intestine and the intestinal wall itself as well as any internal organs it encounters.

Pain typically radiates from the pit of the abdomen through to the back with nausea, vomiting, low-grade fever, and shock. Some patients exhibit none of these save shock. There may be evidence of intra-abdominal bleeding.

Causes include direct trauma, overindulgence in alcoholic beverages, viral and bacterial infections, duodenal ulcer perforation into the pancreas, certain metabolic insults, and toxicity from some pharmacological drugs.

The diagnosis is made by ultrasound with supporting evidence from elevated pancreatic enzyme levels (amylase and lipase). These people usually have elevated white cell counts.

Acute pancreatitis is a medical emergency and must be treated in a hospital setting. In addition to the usual management doctors in nutritional medicine have noted that intramuscular selenium followed by repeat doses 24 hours later, then daily doses are useful in the management of this disorder. Only doctors who practice nutritional medicine have a clue about the use of selenium for this indication.

In the acute stage of acute pancreatitis the patient should have nothing by mouth, intravenous feeding should be instituted, calcium and magnesium levels maintained, pain managed, and the cause of the disorder treated. This may involve surgery.

Chronic pancreatitis may result from one or more bouts of acute pancreatitis and this condition is marked by radiologic evidence of calcification of the pancreas, passage of undigested fat in the stool, diabetes, vitamin B12 deficiency, and poor digestion due to loss of pancreatic enzymes. Also a cyst-like condition may develop requiring surgery.

The most important aspect in the treatment of acute pancreatitis is supportive care. This includes replacement of fluid and electrolytes, correction of metabolic abnormalities such as symptomatic hypercalcemiaand nutritional support.  Other measures such as the use of nasogastric suction and antibiotics should be decided on a case-by-case basis.

Agents that have been used to inhibit pancreatic secretion have not been found to be useful in altering the course in acute pancreatitis. These include somatostatin and glucagon. Protease inhibitors, which are effective in laboratory studies, have not been shown to be useful in clinical pancreatitis.

Emergency surgery is not indicated in mild acute pancreatitis. Some surgical procedures such as resection of necrotictissue and peritoneal lavagemay have a role in select patients with severe, progressive necrotizing pancreatitis or pancreatic abscess. Cholecystectomy has been demonstrated to be effective in patients with recurrent acute pancreatitis and microlithiasis (Figure 17).

Surgical sphincteroplasty of the pancreatic sphincter is an alternative approach to endoscopic pancreatic sphincterotomy in patients with pancreatic sphincter dysfunction. Although the patient outcome is the same as for the endoscopic approach, it is more invasive, requiring laparotomy and . duodenotomy

Sphincteroplasty of the minor papilla is indicated for unsuccessful or failed endoscopic minor papilla sphincterotomy in patients with . pancreas divisum

Endoscopic therapy has a therapeutic role in three specific areas in the management of acute pancreatitis: 1) acute gallstone pancreatitis, 2) recurrent pancreatitis due to pancreatic sphincter dysfunction, and 3) recurrent pancreatitis due to . pancreas divisum The rationale for endoscopic therapy in each area is the relief of obstruction to flow of pancreatic juice.

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Although it would seem logical that removal of the gallstones from the common bile duct early in acute gallstone pancreatitis would improve the clinical course, there is a lack of a “predictable” good outcome as suggested by propective clinical trials. It appears, however, that the patients with suspected stones who benefit from early ERCP are those with evidence of biliary obstruction such as jaundice or dilation of the bile duct and severe pancreatitis. Further clinical trials are needed before more definitive recommendations can be made. In a subgroup of patients with acute recurrent pancreatitis and ,microlithiasis endoscopic sphincterotomy has been shown to significantly reduce the frequency of attacks (Figure 18).

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With the advent of manometric studies of the pancreatic sphincter, many cases of so-called idiopathic recurrent pancreatitis are now known to be a result of pancreatic sphincter dysfunction. Endoscopic pancreatic sphincterotomy may be expected to have a good outcome in up to 90% of these patients. There are two techniques for endoscopic pancreatic sphincterotomy; one is with a pull-type sphincterotome followed by stenting of the pancreatic duct and the second is with a needle-knife sphincterotome performed over a pancreatic stent. Following pancreatic sphincterotomy there may be tissue swelling that could result in obstruction to pancreatic outflow. Therefore, short-term pancreatic stenting is indicated when pancreatic sphincterotomy is performed to maintain patency of pancreatic outflow (Figure 19).

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Endoscopic minor papilla sphincterotomy is effective treatment for patients with recurrent pancreatitis and pancreas divisum (Figure 20). Good long-term results are found in about 70% of patients but may be significantly less if there are changes of chronic pancreatitis. 

There are two techniques for endoscopic minor papilla sphincterotomy; one is with a pull-type sphincterotome followed by stenting of the pancreatic duct and the second is with a needle-knife sphincterotome performed over a pancreatic stent (Figure 21). Following pancreatic sphincterotomy there may be tissue swelling that could result in obstruction to pancreatic outflow. Therefore short-term pancreatic stenting is indicated when pancreatic sphincterotomy is performed to maintain patency of pancreatic outflow.

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