Acute pancreatitis prevention and treatment

Acute pancreatitis

Zhang Xiaojuan Ding Xianfei Sun Tongwen

Yu, 33 years old, developed persistent left upper abdominal pain after a big meal and drinking at a party, accompanied by palpitations and chest tightness, but no nausea, vomiting and other symptoms. He went to the hospital for examination and was diagnosed with acute pancreatitis. After 2 days of treatment, his symptoms continued to worsen. He was transferred to our hospital due to poor oxygenation and oliguria and was diagnosed with severe acute pancreatitis. After 31 days of intensive treatment including fasting, gastrointestinal decompression, medication, mechanical ventilation, CRRT, ECMO support, puncture drainage, etc., he was out of danger and discharged smoothly.

Acute pancreatitis (AP) is a common critical disease in emergency and gastroenterology departments. With the improvement of living standards, the incidence rate increases year by year. About 20% of cases can progress to moderately severe pancreatitis or severe severe pancreatitis. The overall mortality rate of acute pancreatitis is about 5%, and the mortality rate of severe acute pancreatitis is relatively high. It is one of the major diseases that seriously endangers people's health and life. It is necessary to popularize science about acute pancreatitis, improve people's awareness, and reduce the incidence rate.

What is acute pancreatitis

Acute pancreatitis is caused by gallstones, hypertriglyceridemia, drinking, overeating, etc., which activate the pancreatic enzymes secreted by the pancreas, leading to self-digestion of the pancreas and peripancreatic tissues, and an inflammatory reaction with pancreatic edema, bleeding, and even necrosis. Clinical manifestations include persistent pain in the upper or middle upper abdomen, radiating to the waist and back, accompanied by nausea and vomiting. In severe cases, sepsis, pancreatic encephalopathy, intra-abdominal hypertension, and multiple organ failure may occur.

What causes acute pancreatitis?

Common causes of acute pancreatitis in my country are biliary, hypertriglyceridemia and alcohol. There are also rare causes: drug-induced, tumor, hypercalcemia, trauma, viral or bacterial infection, etc. Biliary is caused by gallstones, common bile duct stones, bile duct infection, biliary ascariasis, etc., accounting for 60% of acute pancreatitis. Hepatobiliary ultrasound, magnetic resonance imaging, etc. are helpful for judgment. Triglyceride levels ≥11.3mmol/L are the cause of acute pancreatitis. When triglycerides are 5.65mmol/L≤<11.3mmol/L, it is highly suspected to be the cause of acute pancreatitis. Acute pancreatitis may occur in 5% of alcoholics.

Overeating, greasy (high-fat) diet, alcoholism, etc. can induce gallstones to be discharged into the bile duct, causing spasms of the papillary sphincter, increasing triglyceride levels, promoting large amounts of pancreatic juice secretion, and inducing acute pancreatitis. Pregnancy, obesity, smoking, and diabetes are high-risk factors for acute pancreatitis.

How is acute pancreatitis diagnosed?

**Clinical manifestations: **①Symptoms: Sudden upper abdominal pain, which may also present as left upper abdominal or whole abdominal pain, with persistent distending pain, dull pain or knife-like pain, radiating to the waist and back, often accompanied by nausea and vomiting, and abdominal pain that does not ease after vomiting. Severe acute pancreatitis has symptoms such as rapid heart rate, rapid breathing, decreased blood pressure, and oliguria. ②Physical signs: There is often upper abdominal tenderness, and in severe cases, there is abdominal muscle tension, tenderness, rebound pain, and weakened or absent bowel sounds. There may be abdominal distension, cyanosis of the skin around the umbilicus and bilateral abdomen, and systemic jaundice.

**Auxiliary examinations: **① Blood tests: Peripheral blood leukocytes are often significantly elevated; serum amylase>3 times the upper limit of normal; serum lipase>3 times the upper limit of normal; aspartate aminotransferase and lactate dehydrogenase may be elevated, and blood calcium may be reduced; bilirubin may be elevated in biliary pancreatitis; triglycerides ≥11.3mmol/L; C-reactive protein is significantly elevated in pancreatic necrosis. ② Imaging examination: Abdominal B-ultrasound can show pancreatic enlargement, pancreatic abnormalities, and peripancreatic effusion, which can diagnose gallstones and understand the condition of the bile duct; CT examination (Figure 1) is of great value in the diagnosis, differential diagnosis, and assessment of severity of acute pancreatitis; MRI examination can detect peripancreatic fat necrosis that is difficult to diagnose with enhanced CT, and can distinguish pancreatic pseudocysts from encapsulated necrosis; MRCP can diagnose bile duct and pancreatic duct lesions.

Figure 1 CT manifestations of acute pancreatitis

Classification of severity of acute pancreatitis

Mild acute pancreatitis: There are clinical manifestations and elevated amylase and lipase in blood draws, no organ failure, and no local or systemic complications. It is often treated in the gastroenterology department and usually recovers within 1-2 weeks. The mortality rate is extremely low.

Moderately severe acute pancreatitis: There are clinical manifestations and elevated levels of amylase and lipase in blood draws, local complications or systemic complications, which may be accompanied by transient organ failure. It needs to be treated in the gastroenterology department or ICU, and the mortality rate is <5%.

Severe acute pancreatitis: accompanied by persistent organ failure, requiring invasive measures such as ventilator, CRRT, ECMO, etc. to support rescue treatment in the ICU, long hospitalization time, and the mortality rate can reach 30%-50%.

Management of acute pancreatitis

If you have sudden persistent upper abdominal pain, or sudden persistent pain after overeating, which radiates to the back, or symptoms such as nausea and vomiting, you should consider the possibility of acute pancreatitis and go to the hospital as soon as possible to check blood and urine amylase, etc.

Mild acute pancreatitis should be treated in a primary hospital, with a short-term fast, and the diet should be resumed as soon as the symptoms are relieved. When there is abdominal distension, gastrointestinal decompression, nasogastric feeding of raw rhubarb, magnesium sulfate, lactulose, etc. to promote defecation, and rhubarb water should be used for enema. Fluid resuscitation should be performed according to heart rate, blood pressure, urine volume, etc., acid and enzyme inhibitory drugs should be used, analgesic treatment should be considered when the pain is severe, anti-infection treatment should be performed for those with concurrent infection, and traditional Chinese medicine treatment can be performed if conditions permit. ERCP should be performed as soon as possible for those with concurrent acute cholecystitis, and ERCP treatment should also be performed for those with biliary obstruction.

For severe pancreatitis, basic treatment is provided and life-saving treatments such as blocking systemic inflammatory response, preventing intra-abdominal hypertension, anti-infection, and organ function support (including respiratory, circulatory, and kidney, etc.) are carried out.

Prevention of acute pancreatitis

**Dietary precautions: **Avoid overeating, drinking a lot of alcohol, and reducing the intake of greasy food. Be careful when eating during the recovery period. Symptoms such as abdominal pain, bloating, and diarrhea indicate that the gastrointestinal tract cannot tolerate fat digestion and absorption. Reduce fat and protein in the diet. For mild acute gallstone pancreatitis and those with gallstones, the gallbladder should be removed. After discharge from the hospital for moderate to severe pancreatitis or severe pancreatitis, greasy food should not be eaten before the gallbladder is removed. Even after the pancreatitis is cured, patients with hypertriglyceridemia should follow a long-term low-fat diet and abstain from alcohol. Alcoholic pancreatitis should abstain from alcohol.

**Precautions for preventing recurrence: **High-risk groups such as gallbladder or bile duct stones, hypertriglyceridemia, alcoholics, and pregnant women should have regular checkups. ERCP should be performed for common bile duct stones; people with hypertriglyceridemia should follow a low-fat diet, control their weight, and have their blood lipids checked regularly. Oral lipid-lowering drugs may be required; alcoholics should completely quit drinking; pregnant women should have their blood lipids, liver function, and liver and gallbladder ultrasounds tested during prenatal checkups to avoid overnutrition.

References:

[1]. Chinese Medical Association Emergency Medicine Branch and Shanghai Medical Association Emergency Medicine Branch, Expert consensus on emergency diagnosis and treatment of acute pancreatitis. Chinese Journal of Emergency Medicine, 2024. 33(4): pp. 470-479.

[2]. Pancreatic Disease Group of the Chinese Society of Gastroenterology, Editorial Board of the Chinese Journal of Pancreatic Diseases and Editorial Board of the Chinese Journal of Gastroenterology, Chinese Guidelines for the Diagnosis and Treatment of Acute Pancreatitis. Chinese Journal of Gastroenterology, 2019. 39(11): pp. 721-730.