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Acute Pancreatitis ACUTE PANCREATITIS Edited by Luis Rodrigo Acute Pancreatitis Edited by Luis Rodrigo Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2011 InTech All chapters are Open Access distributed under the Creative Commons Attribution 3.0 license, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. As for readers, this license allows users to download, copy and build upon published chapters even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. Notice Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Vedran Greblo Technical Editor Teodora Smiljanic Cover Designer InTech Design Team Image Copyright Sebastian Kaulitzki, 2011. Used under license from Shutterstock.com First published December, 2011 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from [email protected] Acute Pancreatitis, Edited by Luis Rodrigo p. cm. 978-953-307-984-4 free online editions of InTech Books and Journals can be found at www.intechopen.com Contents Preface IX Part 1 Etiology 1 Chapter 1 Acute Biliary Pancreatitis 3 Mehmet Ilhan and Halil Alıs Chapter 2 Acute Pancreatitis Induced by Drugs 17 Karel Urbánek, Ilona Vinklerová, Ondřej Krystyník and Vlastimil Procházka Chapter 3 Obesity and Acute Pancreatitis 35 Davor Štimac and Neven Franjić Chapter 4 Acute Pancreatitis During Pregnancy 47 Tea Štimac and Davor Štimac Chapter 5 Pancreatitis in Children 55 Alfredo Larrosa-Haro, Carmen A. Sánchez-Ramírez and Mariana Gómez-Nájera Chapter 6 Pancreatitis in Cystic Fibrosis and CFTR-Related Disorder 67 Michael J. Coffey and Chee Y. Ooi Chapter 7 Diabetes or Diabetes Drugs: A Cause for Acute Pancreatitis 91 Leann Olansky Part 2 Pathogenesis 99 Chapter 8 Role of Peritoneal Macrophages on Local and Systemic Inflammatory Response in Acute Pancreatitis 101 Marcel Cerqueira Cesar Machado and Ana Maria Mendonça Coelho Chapter 9 Molecular Biology of Acute Pancreatitis 109 Francisco Soriano and Ester C.S. Rios VI Contents Chapter 10 Oxidative Stress and Antioxidative Status in the Acute Pancreatitis 117 Andrzej Lewandowski, Krystyna Markocka-Mączka, Maciej Garbień, Dorota Diakowska and Renata Taboła Chapter 11 Microcirculatory Disturbances in the Pathogenesis of Acute Pancreatitis 141 Dirk Uhlmann Part 3 Diagnosis 171 Chapter 12 Endoscopic Retrograde Cholangiopancreatography-Related Acute Pancreatitis – Identification, Prophylaxis and Treatment 173 Alejandro González-Ojeda, Carlos Dávalos-Cobian, Elizabeth Andalón-Dueñas, Mariana Chávez-Tostado, Arturo Espinosa-Partida and Clotilde Fuentes-Orozco Chapter 13 Endoscopic Retrograde Cholangiopancreatography (ERCP) Related Acute Pancreatitis 197 Zoltán Döbrönte Chapter 14 Nutrition Assessment and Therapy in Acute Pancreatitis 215 Vanessa Fuchs-Tarlovsky and Krishnan Sriram Part 4 Treatment 233 Chapter 15 Changes in the Management of Treatment in Acute Pancreatitis Patients 235 Juraj Bober, Jana Kaťuchová and Jozef Radoňak Chapter 16 Hypertriglyceride Induced Acute Pancreatitis 259 Joshua Lebenson and Thomas Oliver Chapter 17 The Role of Percutaneous Drainage in the Treatment of Severe Acute Pancreatitis on the Basis of the Modified Atlanta Classification 279 Zsolt Szentkereszty, Róbert Kotán and Péter Sápy Preface It is a great pleasure r to be the editor of this interesting book about Acute Pancreatitis, written by an international group of experts, doctors, university professors, and investigators, experienced in this field. Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting and its incidence is rising. Presentations range from a mildself- limiting condition which usually responds to conservative management,to one with significant morbidity and mortality in its most severe forms. While clinical criteria are necessary to make the initial diagnosis, contrast-enhanced CT is the mainstay of imaging and has a vital role in assessing the extent and evolution of the disease and its associated complications. Disease severity is best predicted from a number of clinical scoring systems which can be applied at diagnosis in association with repeated clinical assessment, measurement of acute inflammatory markers, and CT. Establishing a biliary etiology in acute pancreatitis is clinically important because of the potential need for invasive treatment, such as endoscopic retrograde cholangiopancreatography. The etiology of acute biliary pancreatitis (ABP) is multifactorial and complex. Passage of small gallbladder stones or biliary sludge through the ampulla of vater. seems to be important in the pathogenesis of ABP. Other factors such as, anatomical variations associated with an increased biliopancreatic reflux, bile and pancreatic juice exclusion from the duodenum, and genetic factors, might contribute to the development of ABP. A diagnosis of a biliary etiology in acute pancreatitis is supported by both laboratory and imaging investigations. An increased serum level of alanine aminotransferase (>1.0 microkat/l) is associated with a high probability of gallstone pancreatitis (positive predictive value 80-90%). Confirmation of choledocholithiasis is most accurately obtained using endoscopic ultrasonography or magnetic resonance cholangiopancreatography. Prophylactic antibiotics are not effective in reducing the incidence of (peri)-pancreatic infection in patients with severe disease (or even documented necrotizing pancreatitis). The only rational indication for antibiotics is documented infection. X Preface Recurrent acute pancreatitis is a common clinical problem. Most cases of pancreatitis are identified by a careful history and physical examination. Despite advanced evaluation, the cause is not apparent in about 10% of cases. The etiology of recurrent acute pancreatitis appears to be multifactorial, with genetic and environmental influences playing a significant role. The strength of evidence for certain etiologies is highly variable, and natural history data is limited. Controversy exists regarding the most appropriate diagnostic and therapeutic approach. Recurrent acute pancreatitis often represents a continuum with chronic pancreatitis. Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey up to 25%, 52%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis, increase morbidity and mortality to a lesser degree. Luis Rodrigo PhD HUCA, Spain Part 1 Etiology 1 Acute Biliary Pancreatitis Mehmet Ilhan and Halil Alıs Ministry of Health Bakırkoy, Dr Sadi Konuk Training and Research Hospital General Surgery, Istanbul, Turkey 1. Introduction Acute pancreatitis is an inflammatory disease of the pancreas. The etiology and pathogenesis of acute pancreatitis have been intensively investigated for centuries worldwide. It can be initiated by several factors, including gallstones, alcohol, trauma, infections and hereditary factors. About 75% of pancreatitis is caused by gallstones or alcohol. In this chapter we discuss the causes, diagnosis, imaging findings, therapy, and complications of acute biliary pancreatitis. 2. Anatomy and physiology The pancreas is perhaps the most unforgiving organ in the human body, leading most surgeons to avoid even palpating it unless necessary. Situated deep in the center of the abdomen, the pancreas is surrounded by numerous important structures and major blood vessels. Surgeons that choose to undertake surgery on the pancreas require a thorough knowledge of its anatomy. However, knowledge of the relationships of the pancreas and surrounding structures is also critically important for all surgeons to ensure that pancreatic injury is avoided during surgery on other structures. The pancreas is a retroperitoneal organ that lies in an oblique position, sloping upward from the C-loop of the duodenum to the splenic hilum. In an adult, the pancreas weighs 75 to 100 g and is about 15 to 20 cm long. The fact that the pancreas is situated so deeply in the abdomen and is sealed in the retroperitoneum explains the poorly localized and sometimes ill-defined nature with which pancreatic pathology presents. Surgeons typically describe the location of pathology within the pancreas in relation to four regions: the head, neck, body, and tail. The head of the pancreas is nestled in the C-loop of the duodenum and is posterior to the transverse mesocolon. Most of the pancreas drains through the
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