Any severe acute pain in the abdomen or back should suggest the possibility of acute pancreatitis. The diagnosis is established by two of the following three criteria: (1) typical abdominal pain in the epigastrium that may radiate to the back, (2) threefold or greater elevation in serum lipase and/or amylase, and (3) confirmatory findings of acute pancreatitis on cross-sectional abdominal imaging. The pathologic spectrum of acute pancreatitis varies from interstitial pancreatitis, which is usually a mild and self-limited disorder, to necrotizing pancreatitis, in which the degree of necrosis may correlate with the severity of the attack and its systemic manifestations.
Most common causes in the United States are cholelithiasis and alcohol. Others are listed in Table 151-1.
TABLE 151-1CAUSES OF ACUTE PANCREATITIS ||Download (.pdf) TABLE 151-1CAUSES OF ACUTE PANCREATITIS
|Common Causes |
Gallstones (including microlithiasis)
Alcohol (acute and chronic alcoholism)
Endoscopic retrograde cholangiopancreatography (ERCP), especially after biliary manometry
Drugs (azathioprine, 6-mercaptopurine, sulfonamides, estrogens, tetracycline, valproic acid, anti-HIV medications, 5-aminosalicylic acid [5-ASA])
Trauma (especially blunt abdominal trauma)
Postoperative (abdominal and nonabdominal operations)
|Uncommon Causes |
Vascular causes and vasculitis (ischemic-hypoperfusion states after cardiac surgery)
Connective tissue disorders and thrombotic thrombocytopenic purpura (TTP)
Cancer of the pancreas
Infections (mumps, coxsackievirus, cytomegalovirus, echovirus, parasites)
Autoimmune (e.g., type 1 and type 2)
|Causes to Consider in Pts with Recurrent Bouts of Acute Pancreatitis Without an Obvious Etiology |
Occult disease of the biliary tree or pancreatic ducts, especially microlithiasis, biliary sludge
Metabolic: Hypertriglyceridemia, hypercalcemia
Anatomic: Pancreas divisum
Intraductal papillary mucinous neoplasm (IPMN)
Can vary from mild abdominal pain to shock. Common symptoms: (1) steady, boring pain in the epigastricand periumbilical region may radiate to the back, chest, flanks, and lower abdomen; (2) nausea, vomiting, abdominal distention.
Physical examination: (1) low-grade fever, tachycardia, hypotension; (2) erythematous skin nodules due to subcutaneous fat necrosis; (3) basilar rales, pleural effusion (often on the left); (4) abdominal tenderness and rigidity, diminished bowel sounds, palpable upper abdominal mass; (5) Cullen’s sign: blue discoloration in the periumbilical area due to hemoperitoneum; (6) Turner’s sign: blue-red-purple or green-brown discoloration of the flanks due to tissue catabolism of hemoglobin.
Serum amylase: Large elevations (>3 × normal) virtually assure the diagnosis if salivary gland disease and intestinal perforation/infarction are excluded. However, normal serum amylase does not exclude the diagnosis of acute pancreatitis, and the degree of elevation does not predict severity of pancreatitis. Amylase levels typically return to normal in 3–7 days.
Serum lipase level: Serum lipase is the preferred test for diagnosis of acute pancreatitis. Increases in parallel with amylase level and measurement of both tests ...