Description

Acute inflammatory process of the pancreas with variable involvement of regional tissue or remote organ systems:

• Inflammatory episode with symptoms related to intrapancreatic activation of enzymes with pain, nausea, and vomiting and associated intestinal ileus
• Varies widely in severity (including death), complications, and prognosis
• Complete structural and functional recovery, provided no necrosis or pancreatic ductal disruption

Epidemiology

• 1–5/10,000
• Predominant age: None
• Predominant sex: Male = Female

Prevalence
Acute: 19/10,000

Risk Factors

Genetics
Hereditary pancreatitis is a rare condition with an autosomal-dominant inheritance pattern.

General Prevention

• Avoidance of alcohol excess, especially over a prolonged period
• Avoidance of cigarette smoking
• Correction of underlying causes (hypertriglyceridemia or hypercalcemia)
• Discontinuation of medications associated with pancreatitis as soon as it is diagnosed
• Cholecystectomy if symptomatic cholelithiasis

Pathophysiology

Autodigestion of the pancreas, interstitial edema with severe 3rd spacing, hemorrhage, necrosis, release of vasoactive peptides, acute fluid collection (within 6 weeks), pseudocyst or postnecrotic collection (>6 weeks), pancreatic ductal disruption, injury to surrounding vascular structures such as the splenic vein (thrombosis) and splenic artery (pseudoaneurysm)

Etiology

• Alcohol
• Gallstones (including microlithiasis)
• Trauma/Surgery
• Acute discontinuation of medications for diabetes or hyperlipidemia
• Following endoscopic retrograde cholangiopancreatography (ERCP)
• Medications (most common, but not exhaustive list):
  • ACE inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Thiazide diuretics and furosemide
  • Antimetabolites (Purinethol and azathioprine) (1)[A]
  • Corticosteroids
  • Exenatide (Byetta) (2)[A]
  • Pentamidine
  • Statins, especially simvastatin (1)[A]
  • Pancreatitis may occur only after several months' administration of some of the implicated medications.
  • When a patient presents with pancreatitis, all medications should be reviewed in the PDR and accessible literature and should be continued only if the benefit justifies the risk of continuing a potential cause of pancreatitis, especially if no other causes are identified.
• Metabolic causes:
  • Hypertriglyceridemia
  • Hypercalcemia
  • Acute renal failure
  • Hereditary causes (uncommon)
  • Systemic lupus erythematosus/polyarteritis
  • Infections (list not exhaustive):
    • Mumps, coxsackie, cryptosporidiosis
• Penetrating peptic ulcer (rare)
• Cystic fibrosis and CFTR gene mutations
• Tumors (e.g., ampullary)
• Pancreas divisum
• Sphincter of Oddi dysfunction
• Scorpion venom
• Vascular disease
• Acute fatty liver of pregnancy
• Idiopathic

Commonly Associated Conditions

• Consider coexistent alcohol withdrawal, alcoholic hepatitis, and ascending cholangitis.
• Obesity increases severity, local complications, and mortality (3)[A].