THE CLINICAL SYNDROME
Acute pancreatitis is one of the most common causes of abdominal pain. The incidence of acute pancreatitis is approximately 0.5% of the general population with a mortality rate of 1% to 1.5%. In the United States, acute pancreatitis is most commonly caused by alcohol, with gallstones being the most common cause in most European countries. There are many causes of acute pancreatitis. In addition to alcohol and gallstones, other common causes of acute pancreatitis include viral infections, tumor, and medications.
Abdominal pain is a common feature in acute pancreatitis. It may range from mild to severe and is characterized by steady, boring epigastric pain that radiates to the flanks and chest. The pain is worse with supine position, and the patient with acute pancreatitis will often prefer sitting with the dorsal spine flexed and the knees drawn up to the abdomen. Nausea, vomiting and anorexia are also common features of acute pancreatitis.
SIGNS AND SYMPTOMS
The patient with acute pancreatitis will appear ill and anxious. Tachycardia and hypotension due to hypovolemia are common, as is low-grade fever. Saponification of subcutaneous fat is seen in approximately 15 % of patients suffering form acute pancreatitis, as are pulmonary complications including pleural effusions and pleuritic pain that may compromise respiration. Diffused abdominal tenderness with peritoneal signs are invariably present. A pancreatic mass or pseudocyst due to pancreatic edema may be palpable. If hemorrhage occurs, periumbilical ecchymosis (Cullen’s sign) and flank ecchymosis (Turner’s sign) may be present. Both of these findings suggest severe necrotizing pancreatitis and indicate a poor prognosis. If hypocalcemia is present, Chvostek’s or Trousseau’s sign may be present.
Excessive cunsumption of alcohol is only one of many causes of acute pancreatitis.
Most cases of acute pancreatitis are self-limited and will resolve within 5 to 7 days. Initial treatment of acute pancreatitis is aimed primarily at putting the pancreas at rest. This is accomplished by holding the patient NPO (nothing by mouth) to decrease serum gastrin secretion and, if ileus is present, by instituting nasogastric suction. Short-acting potent opioid analgesics such as hydrocodone represent a reasonable next step if conservative measures do not control the patient’s pain. If ileus is present, parenteral narcotics such as meperidine are a good alternative. Because the opioid analgesics have the potential to suppress the cough reflex and respiration, the clinician must be careful to monitor the patient closely and to instruct the patient in adequate pulmonary toilet techniques. If the symptoms persist, computed tomography-guided celiac plexus block with local anesthetic and steroid is indicated and may help decrease the mortality and morbidity rates associated with the disease. As an alternative, continuous thoracic epidural block with local anesthetic, opioid, or both may provide adequate pain control and allow the patient to avoid the respiratory depression associated with systemic opioid analgesics.