P.G. Lankisch, M. Buchler, J. Mossner, S. Miiller-Lissner A Primer of Pancreatitis The gastroenterological primers are edited by s. Miiller-Lissner and H.R. Koelz. Springer Berlin Heidelberg New York Barcelona Budapest Hong Kong London Milan Paris Santa Clara Singapore Tokyo P. G. Lankisch M. Buchler J. Mossner S. Miiller-Lissner A Primer of Pancreatitis , Springer Prof. Dr.med. P.G. Lankisch Prof. Dr. med. J. Mossner Department of Medicine Department of Internal Medicine II Municipal Hospital University of Leipzig Bogelstr. 1 Philipp-Rosenthal-Str. 27 21339 Luneburg 04103 Leipzig Prof. Dr.med. M. Buchler Prof. Dr. S. Millier-Lissner Department of Visceral and Department of Medicine Transplantation Surgery Park-Klinik Weissensee University of Bern (Inselspital) Schonstr. 80 Murtenstr. 35 13086 Berlin CH -3010 Bern ISBN-13:978-3-540-63259-7 Die Deutsche Bibliothek -CIP-Einheitsaufnahme A primer of pancreatitis 1 P. G. Lankisch ... -Berlin; Heidelberg; New York; Barcelona ; Budapest ; Hong Kong ; London; Milan ; Paris ; Santa Clara ; Singapore; Tokyo: Springer, 1997 ISBN-13:978-3-540-63259-7 e-ISBN-13:978-3-642-60870-4 DOl: 10.1007/978-3-642-60870-4 This work is protected by copyright. All resulting rights are reserved, particu larly those of translation, photocopying, conveyance, extraction of figures and tables, electronic transmission, microfilming or reproduction in any other way and storage in data processing systems, in whole or in part. Reproduction of this work or of a part of this work is, even in individual cases, permissible only within the limits of the regulations of the current version of the Copyright Act of the Federal Republic of Germany of 9th September 1965. A fee is basically payable for this. Infringements are subject to the legal sanctions of the Copy right Act. 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Hippmann, Schwanstetten Typesetting and reproduction of figures: RTS Wiesenbach SPIN 10634322 2123/3134 - 5432 1 0 -Printed on acid-free paper Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Physiology of pancreatic secretion. . . . . . . . . . . . . . . . . . 4 Acute pancreatitis ................................ 6 Aetiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Pathogenesis ..................................... 8 Incidence, prognosis and recurrence . . . . . . . . . . . . . . .. 10 Diagnosis: overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 12 - Symptoms..................................... 14 - Laboratory tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 16 - Abdominal ultrasound . . . . . . . . . . . . . . . . . . . . . . . . .. 18 - Abdominal computed tomography. . . . . . . . . . . . . .. 20 - Endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic papillotomy (EPT)... . . . .. 22 - Estimation of prognosis. . . . . . . . . . . . . . . . . . . . . . . .. 24 Therapy: overview .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26 - Conservative therapy. . . . . . . . . . . . . . . . . . . . . . . . . . .. 28 - Surgery........................................ 30 - Practical management. . . . .. . . . . . . . . . . . . . . . . . . . .. 32 Chronic pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 34 Aetiology and pathogenesis . . . . . . . . . . . . . . . . . . . . . . .. 34 Pathogenesis of complications. . . . . . . . . . . . . . . . . . . . .. 36 Incidence, course and prognosis. . . . . . . . . . .. ....... 38 Diagnosis: overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4C - Symptoms..................................... 42 - Laboratory tests and function tests . . . . . . . . . . . . . .. 44 - Abdominal ultrasound. . . . . . . . . . . . . . . . . . . . . . . . .. 46 - Abdominal computed tomography . . . . . . . . . . . . . .. 48 - Endoscopic retrograde cholangiopancreaticography (ERCP) ........................................ 50 v Contents Therapy: overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 52 - General measures and pain therapy ... . . . . . . . . . .. 54 Pancreatic enzyme supplementation therapy. . . . . .... 56 - Operative endoscopy. ........................... 58 - Surgery........................................ 60 - Practical management. . . . . . . . . . . . . . . . . . . . . . . . . .. 62 - Therapy of complications ....................... 64 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 67 Introduction Acute pancreatitis is an often life-threatening gastroenterological disease. Early diagnosis and reliable assessment of the severity of acute pancreatitis can have a decisive influence on the patient's prognosis. Alcohol consumption has increased considerably throughout the world in recent years and, in Germany for example, now amounts to between 10 and 12 litres of pure alcohol per head of the population annually. General practitioners and clinicians are therefore increasingly being confronted with patients who drink too much alcohol and complain of upper abdomi nal pain. Alcohol is the most common cause of chronic pancreatitis. The diagnostic interval (from the onset of symptoms of chronic pancreatitis to diagnosis) is currently between three and five years, a long and certainly unacceptable time. The aim of this Primer of Pancreatitis is to provide doctors working in general practice or in hospital with the most important information con cerning acute and chronic pancreatitis. The emphasis is directed to aspects relevant to practical management. The advise is based on the latest state of the art. Paul Georg Lankisch Markus Buchler Joachim M6ssner Stefan Miiller-Lissner Acknowledgement. We would like to express our gratitude to M.A. Rudmann, M.D., of Solvay Pharmaceuticals GmbH for supporting the pub lication of the English version of the "Pankreatitisfibel". 1 Definitions Acute pancreatitis The severity of the clinical state and the morphological alterations do not always agree. Acute pancreatitis can recur. Chronic pancreatitis The loss of function often becomes clinically noticeable only when stea torrhoea and/or diabetes mellitus develop. Chronic obstructive pancreatitis is presented as a special form in about 5% of cases. A cure can be obtained after eliminating the obstruction. Differential diagnosis In many cases, only continuous observation allows an acute episode to be classed as either acute pancreatitis or chronic pancreatitis. 2 Definitions Acute pancreatitis • Acute inflammation of the exocrine pancreas - mild form: oedematous pancreatitis - severe form: necrotising pancreatitis • Mostly with severe upper abdominal pain • Increased serum amylase and lipase levels • Complete recovery (80%) or recovery with sequelae / transition to chronic pancreatitis (20%) Chronic pancreatitis • Chronic inflammation of the exocrine pancreas - fibrosis with destruction of the parenchyma - often complicated course • Mostly with recurrent or persistent upper abdominal pain • No recovery, mostly with progressive functional impairment 3 Physiology~ ancreatic secretion Compensation of functional impairment The digestion of carbohydrates can be partially taken over by salivary amy lase, and the digestion of proteins by pepsin from the stomach and protea ses from the small intestine. In contrast, the digestion of fat cannot be taken over adequately by extrapancreatic lipases. Fat digestion Cholecystokinin stimulates both pancreatic enzyme secretion and gall blad der contraction. The interplay between bile salts, lipase and colipase is important for optimal fat digestion. Protective mechanisms The pancreas employs several factors to protect itself from self-digestion. The proteases are secreted as proenzymes which are activated by entero kinase only in the duodenum. Activation of enzymes in the acinar cell is prevented by separate storage of lysosomal and digestive enzymes. Finally, protease inhibitors are produced. 4