Table Of ContentP.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
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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
