Pancreatitis - Diagnosis and Therapy

1. A Glimpse of Pancreatitis History 17
1.1. Early thoughts on pancreatic disease 17
1.1.1. Pancreatic anatomy 17
1.2. Acute pancreatitis 17
1.2.1. Nicholaes Tulp 17
1.3. A new interest in pancreatitis 18
1.3.1. Reginald Fitz 19
1.4. Two types of pancreatitis 19
1.4.1. Nicholas Senn 20
1.5. Pancreatitis pathophysiology 20
1.5.1. Opie's common channel hypothesis 20
1.5.2. Alcoholic pancreatitis 21
1.6. Biochemical diagnosis 21
1.7. Classification of acute pancreatitis 22
1.8. Attempts to treat acute pancreatitis 22
2. Epidemiology of Acute Pancreatitis 27
3. Genetics of Pancreatitis 34
3.1. Cationic trypsinogen (PRSS1) 34
3.2. Anionic trypsinogen (PRSS2) 35
3.3. Serine protease inhibitor, Kazal type 1 (SPINK1) 35
3.4. Chymotrypsinogen C (CTRC) 36
3.5. Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) 37
3.6. Alcohol-related chronic pancreatitis 38
4. Physiology of the Normal Pancreas 41
4.1. Exocrine pancreas 41
4.1.1. Enzymes for protein digestion 41
4.1.2. Enzymes for lipid digestion 43
4.1.3. Enzymes for carbohydrate digestion 43
4.1.4. Enzymes for digestion of RNA and DNA 43
4.1.5. Other enzymes and proteins 44
4.1.6. Synthesis and exocytosis of pancreatic digestive enzymes 44
4.1.7. Regulation of enzyme secretion 44
4.2. Endocrine pancreatic function 45
5. Physiology of Acute and Chronic Pancreatitis 47
5.1. Pathophysiology of pancreatic exocrine insufficiency 56
6. Pathology of Pancreatitis 63
6.1. Acute pancreatitis 63
6.1.1. Gross pathology 63
6.1.2. Microscopic findings 64
6.1.3. Complications 64
6.1.3.1. Pseudocyst formation 64
6.1.3.2. Bacterial infection 65
6.2. Chronic pancreatitis 65
6.2.1. Gross pathology 65
6.2.2. Microscopic findings 66
6.2.3. Complications 67
6.2.4. Special forms 67
6.2.4.1. Hereditary chronic pancreatitis 68
6.2.4.2. Tropical pancreatitis 68
6.2.4.3. Obstructive pancreatitis 68
6.2.4.4. Autoimmune pancreatitis 68
6.2.4.5. Groove pancreatitis 70
6.2.5. Chronic pancreatitis and pancreatic cancer 70
7. Classification of Pancreatitis 73
7.1. Acute pancreatitis 73
7.2. Chronic pancreatitis 77
7.3. The new millenniums attempts of classifications 81
8. Acute Pancreatitis 90
8.1. Clinical presentation and laboratory tests 90
8.1.1. Initial symptoms of acute pancreatitis 90
8.1.1.1. Pain 90
8.1.1.2. Other secondary abdominal symptoms 91
8.1.2. Laboratory diagnostic tests of acute pancreatitis 91
8.1.2.1. Enzyme testing frequency 91
8.1.2.2. Amylase 92
8.1.2.3. In critically ill patients 93
8.1.2.4. After propofol 93
8.1.2.5. In smokers 93
8.1.2.6. Urinary trypsinogen-2 93
8.1.3. Hyperlipedaemia 93
8.1.4. Obesity 94
8.1.5. Subcutaneous signs of acute pancreatitis 94
8.1.6. Vascular complications 95
8.1.7. Colonic obstruction and persistent fistulas 95
8.1.7.1. Colonic obstruction in acute pancreatitis 95
8.1.7.2. Fistulas 95
8.2. Severity assessment 96
8.3. Predictors in acute pancreatitis 105
8.3.1. Prognosis in mild acute pancreatitis 106
8.3.2. Prognosis in severe acute pancreatitis 106
8.3.3. Clinical differing mild from severe acute pancreatitis 107
8.3.4. Other prognostic single factors 109
8.3.5. Scoring systems 111
8.3.6. The harmless acute pancreatitis score 113
8.4. Imaging 114
8.4.1. Abdominal ultrasound 114
8.4.2. Cross-sectional imaging 120
8.5. Therapy 124
8.5.1. Conservative treatment 124
8.5.2. Endoscopy 133
8.5.3. Endoscopic necrosectomy 145
8.5.4. Invasive management in acute pancreatitis 148
9. Chronic Pancreatitis 156
9.1. Diagnosis 156
9.1.1. Clinical presentation 156
9.1.2. Laboratory tests 157
9.1.3. Imaging 159
9.1.3.1. Abdominal ultrasound 159
9.1.3.2. Cross-sectional imaging 167
9.1.4. Pancreatic function tests 171
9.1.4.1. Direct pancreatic function tests 172
9.1.4.2. Indirect pancreatic functional tests 174
9.2. Therapy 183
9.2.1. Multidisciplinary approach for alcoholic chronic pancreatitis 183
9.2.1.1. Medical therapy 186
9.2.1.2. Nutrition before and after Surgery 193
9.2.1.3. Pain management 196
9.2.1.3.1. Lifestyle changes 198
9.2.1.3.2. Analgesics 198
9.2.1.3.3. Adjuvant analgesics 200
9.2.1.3.4. Invasive pain treatment 200
9.2.2. Interventional endoscopy 202
9.2.3. Surgical therapy 209
9.2.4. Minimally invasive surgery 213
9.2.5. Islet cell autotransplantation 217
10. Autoimmune Pancreatitis 223
10.1. Clinical features 223
10.1.1. Type 1 AIP 223
10.1.2. Type 2 AIP 223
10.2. Diagnosis 224
10.2.1. Laboratory findings 224
10.2.2. Diagnostic criteria and differential diagnosis 224
10.3. Cross-sectional imaging in autoimmune pancreatitis 230
10.4. Treatment 230
11. Pancreatitis in Children 234
11.1. Background 234
11.2. Acute Pancreatitis 234
11.3. Pancreatitis due to malformation defects in pancreas 236
11.4. Trauma 236
11.5. Recurrent pancreatits 236
11.6. Chronic pancreatitis 236
11.7. Exocrine pancreatic insufficiency 237
11.8. Autoimmune pancreatitis 237
11.9. Own experience with chronic and recurrent pancreatitis in children 237
11.10. Organisation 238
12. Chronic Pancreatitis in Conjunction with Other Diseases 241
12.1. Primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) 241
12.2. IgG4-associated cholangitis 241
12.3. Connective tissue diseases 241
12.4. Inflammatory bowel diseases (IBD) 242
12.5. Infections 242
13. Organisation of a Modern Chain-Of-Care in Pancreatology 245
14. Teaching in Pancreatology - the Pancreas 2000 Project 248
15. Information in the Internet 250
Index 251