21st April 2024

Disorders of the Pancreas

Acute Pancreatitis

Background

Acute pancreatitis typically presents as epigastric pain and, more often than not, is associated with nausea and vomiting. The two most common causes are alcohol and gallstones. Diagnosis can be confirmed by the presence of at least two of the following three criteria: upper abdominal pain (left upper quadrant or epigastric), serum amylase >3x upper limit of normal, and characteristic findings on imaging (CT is often the modality of choice). Note imaging only needs to be requested if there is diagnostic doubt. Once a diagnosis of acute pancreatitis is made, an abdominal ultrasound should be requested to look for gallstones. Management is initially supportive (fluids, analgesia, antiemetics, and nutrition).

Investigation

Serum amylase, abdominal ultrasound and CT are used in diagnosis. CT is often used in severe cases to look for complications such as necrosis and pseudocyst formation.

Management

This is largely supportive, with IV fluids and anti-emetics. Surgical intervention can be used to drain pseudocysts, and necrosectomy can be used for necrotic tissue.

Chronic pancreatitis

This often presents with epigastric pain, steatorrhea, diabetes (as suggested by raised blood glucose and osmotic symptoms), and malnutrition. It is important to remember that serum amylase may be normal in an acute flare of chronic pancreatitis. The most common cause is alcohol (80%). Other causes include Cystic Fibrosis, recurrent gallstone disease, poorly controlled hemochromatosis, hypertriglyceridemia, and hypercalcaemia.

Faecal elastase can be used to assess exocrine function (this will be low if there is exocrine dysfunction), whilst CT can also be used for diagnosis.

Management involves alcohol and smoking cessation, analgesia, enzyme supplementation (Creon), and proton pump inhibitors.

Autoimmune pancreatitis

Autoimmune pancreatitis is often associated with other autoimmune conditions and associated with raised IgG4 levels. Autoimmune pancreatitis is also less likely to present with abdominal pain in comparison with acute pancreatitis. Patients with autoimmune pancreatitis may develop extra-pancreatic manifestations such as diabetes. Features include obstructive jaundice, which is often painless. Imaging tends to show a characteristic diffuse pancreatic enlargement. This may cause jaundice due to biliary obstruction. The mainstay of management is steroid therapy.

Pancreatic cancer

Pancreatic cancer classically presents as painless obstructive jaundice and weight loss. More often than not, the disease is caught too late, and management is often symptomatic. Surgery is the only cure. Chemotherapy and radiotherapy may produce a small benefit in some cases. The majority of pancreatic primaries are ductal adenocarcinomas (>90%).