PANCREATITIS – TREATMENT AND COMPLICATIONS Edited by Luis Rodrigo Saez Pancreatitis – Treatment and Complications Edited by Luis Rodrigo Saez Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2012 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 First published February, 2012 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] Pancreatitis – Treatment and Complications, Edited by Luis Rodrigo Saez p. cm. ISBN 978-953-51-0109-3 Contents Preface IX Part 1 Etiology 1 Chapter 1 Acute Pancreatitis – The Current Concept in Ethiopathogenesis, Morphology and Complications 3 B. Suresh Kumar Shetty, Ramdas Naik , Adithi S. Shetty, Sharadha Rai, Ritesh G. Menezes and Tanuj Kanchan Chapter 2 Acute Biliary Pancreatitis 13 Morgan Rosenberg, Ariel Klevan and Eran Shlomovitz Chapter 3 Childhood Pancreatitis 29 Ali E. Abdelbasit Part 2 Pathogenesis 57 Chapter 4 Coagulation Abnormalities in Acute Pancreatitis 59 Travis Gould, Safiah Mai and Patricia Liaw Chapter 5 Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis 73 Atsushi Sofuni and Takao Itoi Chapter 6 Recurrent Pancreatitis 85 Vincenzo Neri Part 3 Diagnosis 99 Chapter 7 Acute Pancreatitis: Presentation and Risk Assessment 101 Ashok Venkataraman and Preston B. Rich Chapter 8 Imaging Appearances of Autoimmune Pancreatitis 119 Koji Takeshita VI Contents Chapter 9 Prediction of Post-ERCP Pancreatitis 131 Takayoshi Nishino and Fumitake Toki Part 4 Treatment 147 Chapter 10 Mini Invasive Treatments in Acute Biliary Pancreatitis 149 Juan Carlos Barbella, Diego L. Dip, Anzorena Francisco Suarez, Jorge Dodera and Emiliano Monti Chapter 11 Intra-Abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Surgical Patients (Special Findings in Severe Acute Pancreatitis) 165 Zsolt Bodnár Chapter 12 Traumatic Pancreatitis – Endoscopic and Surgical Management 183 Hirotaka Okamoto and Hideki Fujii Part 5 Complications 195 Chapter 13 Pancreatic Ascites and Pleural Effusion 197 K. Prakash Chapter 14 Emphysematous Pancreatitis 205 Audrius Šileikis Preface It is my great pleasure and honor to present this interesting book Pancreatitis – Treatment and Complications, written by an international group of experts, doctors, university professors and researchers with great experience in this field. Pancreatitis may be acute or chronic. Although they can be caused by similar aetiologies, they tend to follow distinct natural histories. Around 80% of acute pancreatitis diagnoses occur as secondary to gallstone disease and alcohol misuse. This disease is commonly associated with the sudden onset of upper abdominal pain radiating to the back that is usually severe enough to warrant the patient seeking urgent medical attention. The onset of pain may be related to a recent alcohol binge or a rich, fatty meal intake. The patient may appear unwell, be tachycardic and have significant tenderness in the upper abdomen. Overall, 10 to 25% of acute pancreatitis (AP) episodes are classified as severe, leading to an associated mortality rate, of 7 to 30%. 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. All patients with suspected AP should be referred urgently. 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. The passing of small gallbladder stones or biliary sludge through the ampulla of Vater seems to be important in the pathogenesis of ABP. Infectious complications in severe acute pancreatitis are associated with considerable morbidity and mortality. The course of the disease is often protracted, and patients often stay in hospital for several weeks. Diagnosis of infected pancreatic necrosis is difficult, and the treatment consists of source control and antibiotic treatment. Antibiotic use should be rational in terms of a proper indication, a wide pancreatic penetration and long duration. Prophylactic antibiotics are ineffective in reducing the incidence of peri-pancreatic infection in patients with severe disease, or even documented necrotizing pancreatitis. X Preface The only rational indication for antibiotics is documented infection. Pancreatitis is one of the most frequent complications of endoscopic retrograde cholangiopancreatography (ERCP). The placement of a prophylactic pancreatic stent after ERCP can help prevent post-ERCP pancreatitis (PEP). 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. Increased intra-abdominal pressure (IAP), also referred to as intra-abdominal hypertension (IAH), affects organ function in critically ill patients and may lead to abdominal compartment syndrome (ACS). Its diagnosis and treatment are clearly described in this book. Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey rates of up to 25%, 50%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis increase morbidity and mortality to a lesser degree. The presence of ascites and pleural effusion and emphysematous pancreatitis, are less commonly found. We have reviewed in several chapters the computed tomographic findings of complications associated with acute pancreatitis with emphasis on their prognostic significance and impact on clinical management, for their early detection and proper follow-up. Inflammation of the pancreas has many presentations in children and adolescents. The etiology is often elusive, with a great number of cases being idiopathic. However, there have been a number of recent advances in the areas of cell biology, genetics and imaging technology, which should be highlighted. This book provides the reader with a review, with particular emphasis on some of these newer advances. I want to thank all of the authors for their excellent contributions and to the InTech editorial team, especially to Mr Vedran Greblo, for his continuous support and superb and ongoing help when it was needed. Prof. Luis Rodrigo Saez Head of Gastroenterology Service, University Hospital Central of Asturias, Full Professor of Medicine, Oviedo University, Spain Part 1 Etiology 1 Acute Pancreatitis – The Current Concept in Ethiopathogenesis, Morphology and Complications B. Suresh Kumar Shetty1, Ramdas Naik2 , Adithi S. Shetty3, Sharadha Rai4, Ritesh G. Menezes5 and Tanuj Kanchan1 1Department of Forensic Medicine and Toxicology Kasturba Medical College, Mangalore, Manipal University, 2Department of Pathology, Kasturba Medical College, Mangalore, Manipal University, 3Department of Obstetrics & Gynaecology, K. S. Hegde Medical Academy, Mangalore, Nitte University, 4Department of Pathology, Kasturba Medical College, Mangalore, Manipal University, 5Department of Forensic Medicine and Toxicology, Srinivas Institute of Medical Sciences & Research Centre, Mangalore, India 1. Introduction This chapter is a comprehensive approach on etiology, patho-phyosiological and complications of acute pancreatitis and its review will aid in evaluation of acute pancreatitis in-toto. Pancreatitis is the inflammation of the exocrine pancreas which results from injury to the acinar cells. It may be classified as either acute or chronic. Acute pancreatitis is the reversible injury to the pancreatic parenchyma associated with inflammation and is characterized by a recurrent episode of abdominal pain and elevated serum amylase and lipase levels. 2. Etiopathogenesis of acute pancreatitis 2.1 Etiology Acute pancreatitis is relatively common. Among the numerous causes,