Pancreatitis natural history, complications and prognosis

Pancreatitis Main Page
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Overview
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Classification Acute Pancreatitis Chronic Pancreatitis Hereditary Pancreatitis Autoimmune Pancreatitis
Differential Diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Complications

Early Complications

Acute (early) complications of pancreatitis include

• shock,
• Hypocalcemia (low blood calcium),
• High blood glucose,
• Dehydration, and kidney failure (resulting from inadequate blood volume which, in turn, may result from a combination of fluid loss from vomiting, internal bleeding, or oozing of fluid from the circulation into the abdominal cavity in response to the pancreas inflammation, a phenomenon known as third spacing).
• Respiratory complications are frequent and are major contributors to the mortality of pancreatitis. Some degree of pleural effusion is almost ubiquitous in pancreatitis. Some or all of the lungs may collapse (atelectasis) as a result of the shallow breathing which occurs because of the abdominal pain. Pneumonitis may occur as a result of pancreatic enzymes directly damaging the lung, or simply as a final common pathway response to any major insult to the body (i.e. ARDS or Acute Respiratory Distress Syndrome).
• Likewise, SIRS (Systemic inflammatory response syndrome) may ensue.
• Infection of the inflamed pancreatic bed can occur at any time during the course of the disease. In fact, in cases of severe hemorrhagic pancreatitis, antibiotics should be given prophylactically.

Late Complications

• Recurrent pancreatitis and the development of pancreatic pseudocysts. A pancreatic pseudocyst is essentially a collection of pancreatic secretions which has been walled off by scar and inflammatory tissue. Pseudocysts may cause pain, may become infected, may rupture and hemorrhage, may press on and block structures such as the bile duct, thereby leading to jaundice, and may even migrate around the abdomen.

Prognosis

There are several scoring systems used to help predict the severity of an attack of pancreatitis. The Apache II has the advantage being available at the time of admission as opposed to 48 hours later for the Glasgow criteria and Ranson criteria. However, the Glasgow criteria and Ranson criteria are easier to use.

APACHE II

Main article: APACHE II

Ranson Criteria

Main article: Ranson criteria

• At admission:

• Age in years >55years
• White blood cell count > 16000/mcL
• Blood glucose > 11 mmol/L (>200 mg/dL)
• Serum AST > 250 IU/L
• Serum LDH > 350 IU/L

• After 48 hours:

• Hematocrit fall > 10%
• Increase in BUN by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
• Hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
• Hypoxemia (PO2 < 60 mmHg)
• Base deficit > 4Meq/L
• Estimated fluid sequestration > 6L

The criteria for point assignment is that a certain breakpoint be met at anytime during that 48 hour period, so that in some situations it can be calculated shortly after admission. It is applicable to both biliary and alcoholic pancreatitis.

Interpretation

• If the score >=3, severe pancreatitis likely.
• If the score < 3, severe pancreatitis is unlikely

Or

• Score 0 to 2 : 2% mortality
• Score 3 to 4 : 15% mortality
• Score 5 to 6 : 40% mortality
• Score 7 to 8 : 100% mortality

Glasgow Criteria

Glasgow's criteria: The original system used 9 data elements. This was subsequently modified to 8 data elements, with removal of assessment for transaminase levels (either AST (SGOT) or ALT (SGPT) greater than 100 U/L).

• On Admission

• Age > 55 yr
• WBC Count > 15 10 exp 9 /Lit
• Blood Glucose > 10 mmol/L (No Diadetic History)
• Serum Urea > 16 mmol/Lit ( No response to IV fluids)
• Arterial oxygen saturation < 60

• Within 48 hours

• Serum Calcium < 2 mmol/L
• Serum Albumin <32 gm/L
• LDH > 600 units/L
• AST / ALT >600 Units/L