Clinical Review ABC of diseases of liver, pancreas, and biliary system

Acute pancreatitis

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7286.595 (Published 10 March 2001) Cite this as: BMJ 2001;322:595
  1. I J Beckingham,
  2. P C Bornman

    Acute pancreatitis is relatively common, with an annual incidence of 10-20/million population. In more than 80% of patients the disease is associated with alcohol or gall stones, although the ratio of these two causes has a wide geographical variation. Gallstone disease predominates in most UK centres by more than 2:1.

    Causes of acute pancreatitis

    • Gallstones } 80%

    • Alcohol

    • Idiopathic: 10%

    • Endoscopic retrograde cholangiopancreatography or sphincterectomy: 5%

    • Miscellaneous: 5%

      Hyperlipidaemia

      Trauma

      Hyperparathyroidism

      Viral (mumps, Epstein-Barr virus, cytomegalovirus, coxsackievirus)

      Drug induced (thiazide diuretics, angiotensin converting enzyme inhibitors, oestrogens, corticosteroids, azathioprine)

      Anatomical (pancreas divisum, annular pancreas)

      Parasites (Ascaris lumbricoides)

    Pathogenesis and pathological processes

    Apart from mechanical factors such as the passage of gall stones through the ampulla of Vater or cannulation at endoscopic retrograde cholangiopancreatography, little is known about how the disease process begins. What follows is also unclear, but proteolytic enzymes are thought to be activated while still within the pancreatic cells, setting off a local and systemic inflammatory cell response.

    Computed tomogram showing extensive pancreatic necrosis (arrow) spreading into perinephric fat (open arrow head)

    The process is self limiting in most cases and pathologically correlates with oedematous interstitial pancreatitis. In 15-20% of cases the process runs a fulminating course, most commonly within the first week. This is characterised by pancreatic necrosis and associated cytokine activation resulting in multiple organ dysfunction syndrome. The necrotic process mainly affects the peripancreatic tissue (mostly fat) and may spread extensively along the retroperitoneal space behind the colon and into the small bowel mesentery. The necrotic tissue can become infected, probably by translocation of bacteria from the gut.

    Discoloration of flank in patient with acute pancreatitis (Grey-Turner's sign)

    Clinical presentation

    Acute pancreatitis should always be considered in the differential diagnosis of patients with acute abdomen. The clinical presentation may vary considerably and is influenced by the aetiological factor, age, other associated illnesses, the stage of the …

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