Acute pancreatitis
Acute pancreatitis is acinar-cell autodigestion and inflammation of the pancreas, most often from gallstones or alcohol, diagnosed by the revised Atlanta criteria and graded mild, moderately severe, or severe by organ failure. Management centers on early goal-directed lactated Ringer's resuscitation, analgesia, early enteral feeding, and timed ERCP for gallstone pancreatitis with cholangitis, reserving antibiotics for confirmed infected necrosis.
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What this article covers
- Overview
Definition: acute pancreatitis is an inflammatory process of the pancreas driven by premature intra-acinar activation of digestive enzymes (chiefly trypsin), causing autodigestion and a cytokine…
- Epidemiology
Most common GI cause of hospitalization in the United States.
- Risk factors
Gallstones, biliary sludge, and microlithiasis: the leading cause; obstruction at the ampulla by a migrating stone triggers the attack.
- Pathophysiology
Acinar cell injury: an inciting insult causes premature intracellular activation of trypsinogen to trypsin within acinar cells.
- Clinical features
Epigastric pain radiating to the back: severe, constant, acute-onset pain, the hallmark symptom, often worse supine and eased by leaning forward.
- Differential diagnosis
Acute mesenteric ischemia: pain out of proportion to exam, often postprandial or with vascular risk factors, with elevated lactate rather than lipase (acute mesenteric ischemia).
- Diagnosis
Establish the diagnosis with the revised Atlanta classification: 2 of 3 criteria required: (1) acute-onset, severe, persistent epigastric pain, often radiating to the back; (2) serum lipase or…
- Management
Resuscitate first with early, goal-directed IV fluids: lactated Ringer's 1.5 mL/kg/hour IV, adding a 10 mL/kg bolus over 2 hours only if hypovolemia is present; reassess within 6 hours and repeatedly…
- Complications
Multiorgan dysfunction and shock: respiratory failure (including ARDS), acute kidney injury, and hypotension define severe, persistent-organ-failure disease and drive the early-phase mortality peak.
- Prognosis
Most patients recover fully: roughly 80% have mild, self-limited disease with under 1% mortality.
- Prevention
Cholecystectomy before discharge for gallstone pancreatitis: definitively prevents recurrence once the episode resolves.
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- Acute cholangitis
Acute cholangitis is a bacterial infection of an obstructed biliary tree, classically presenting as Charcot triad of fever, right upper quadrant pain, and jaundice and progressing to septic shock when drainage is delayed. Diagnosis follows the Tokyo Guidelines and severity grade, and treatment combines prompt broad-spectrum antibiotics with biliary drainage, most often by ERCP.
- Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
- Choledocholithiasis
Choledocholithiasis is a gallstone that has migrated into the common bile duct, causing obstructive jaundice and cholestatic liver chemistries and predisposing to acute cholangitis and gallstone pancreatitis. Risk is stratified by ASGE criteria and confirmed by MRCP, endoscopic ultrasound, or therapeutic ERCP, which clears the duct before same-admission cholecystectomy.
- Chronic pancreatitis
Chronic pancreatitis is irreversible fibro-inflammatory destruction of the pancreas that produces abdominal pain along with exocrine and endocrine insufficiency, most often from long-term alcohol use in adults and cystic fibrosis in children. Diagnosis rests on CT or MRI showing calcifications and ductal change, and management combines alcohol and tobacco cessation, staged analgesia, pancreatic enzyme replacement, and endoscopic or surgical drainage for ductal obstruction.
- Hypertriglyceridemia
Hypertriglyceridemia is a fasting triglyceride level of 150 mg/dL or higher, usually asymptomatic and found on screening, that raises atherosclerotic cardiovascular risk and, at very high levels, causes acute pancreatitis. First-line treatment is lifestyle change, with a statin added for cardiovascular risk reduction and fenofibrate reserved for pancreatitis prevention when severe.
- Cholelithiasis
Cholelithiasis is the presence of gallstones in the gallbladder, most often cholesterol stones from bile supersaturation, and is asymptomatic in most patients. Symptomatic disease presents as biliary colic, self-limited postprandial right upper quadrant pain without fever, diagnosed by right upper quadrant ultrasound and treated with elective laparoscopic cholecystectomy.
- Peptic ulcer disease
Peptic ulcer disease is a mucosal break in the stomach or duodenum caused chiefly by Helicobacter pylori infection or NSAID use, diagnosed by upper endoscopy with biopsy of gastric ulcers to exclude malignancy. Treatment eradicates H. pylori when present, stops the ulcerogenic drug, and heals the ulcer with a proton pump inhibitor, while its complications of bleeding, perforation, and obstruction drive most of its morbidity.
- Acute mesenteric ischemia
Acute mesenteric ischemia is an abrupt drop in small-bowel blood flow, most often superior mesenteric artery embolism, presenting as severe abdominal pain out of proportion to an unimpressive early examination. CT angiography confirms the diagnosis, and survival depends on immediate resuscitation, antibiotics, and anticoagulation followed by urgent revascularization or resection before infarction and peritonitis develop.