Akut Pankreatit
Özet
Akut pankreatit, pankreasın ani gelişen ve ciddiyetine göre %3 ile %17 arasında mortalite gösteren akut enflamatuar bir hastalığıdır. En belirgin semptomu epigastrik bölgede başlayan, sıklıkla sırta vuran kalıcı ve şiddetli ağrıdır. Tanı konulabilmesi için karakteristik karın ağrısı, serum amilaz veya lipaz değerlerinin normalin en az 3 katı olması ya da görüntüleme yöntemlerinde pankreatit bulgularının saptanması kriterlerinden en az ikisinin varlığı gereklidir. Atlanta sınıflandırmasına göre intersitiyal ödematöz veya nekrotizan; klinik seyrine göre ise hafif, orta ve ciddi olarak kategorize edilir. Hastalığın ilk aşamasında agresif sıvı replasmanı, opioidlerle ağrı kontrolü ve klinik duruma uygun beslenme desteği kritik önem taşır. Erken dönemde ampirik antibiyotik kullanımı, enfekte nekroz varlığı dışında önerilmemektedir. Komplikasyon yönetiminde kontrastlı tomografi ile nekroz takibi ve minimal invaziv yaklaşımlar tercih edilirken, safra taşına bağlı gelişen vakalarda iyileşme sonrası kolesistektomi planlanmalıdır. Ayrıca, hastaların ilk ataktan sonraki beş yıl içinde yeni gelişen diyabet riski açısından takip edilmesi önerilmektedir.
Acute pancreatitis is an acute inflammatory condition of the pancreas, with mortality rates ranging between 3% and 17% depending on the severity of the disease. The most prominent clinical feature is severe, persistent epigastric pain that frequently radiates to the back. Diagnosis requires the presence of at least two of three criteria: characteristic abdominal pain, serum amylase or lipase levels elevated to at least three times the normal upper limit, and distinctive radiological findings. Based on the Atlanta classification, it is categorized as interstitial edematous or necrotizing, and clinically graded as mild, moderate, or severe. Initial management focuses heavily on aggressive fluid resuscitation, pain control via intravenous opioids, and appropriate nutritional support. Prophylactic antibiotic administration is explicitly discouraged unless infected necrosis is confirmed. Complication management relies on contrast-enhanced computed tomography for necrosis surveillance, favoring minimally invasive debridement when necessary, while cholecystectomy is recommended following recovery in gallstone-induced cases to prevent recurrence. Additionally, patients carry a significant long-term risk of developing new-onset diabetes within five years post-attack.
Referanslar
Lankisch, P G, Schirren C A, Kunze E. “Undetected fatal acute pancreatitis: why is the disease so frequently overlooked?.” The American journal of gastroenterology vol. 86,3 (1991): 322-6.
Ignacio I T, Ferrer N R, Estrada R B. “Pancreatic panniculitis.” Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva vol. 111,10 (2019): 812-813. doi:10.17235/reed.2019.6116/2018
Yadav D, Agarwal n, Pitchumani C S. “A critical evaluation of laboratory tests in acute pancreatitis.” The American journal of gastroenterology vol. 97,6 (2002): 1309-18. doi:10.1111/j.1572-0241.2002.05766.x
Fortson, M R, Freedman S R, Webster 3rd P D. “Clinical assessment of hyperlipidemic pancreatitis.” The American journal of gastroenterology vol. 90,12 (1995): 2134-9.
Toouli, J, Brooke-Smith M, Bassi C et al. “Guidelines for the management of acute pancreatitis.” Journal of gastroenterology and hepatology vol. 17 Suppl (2002): S15-39. doi:10.1046/j.1440-1746.17.s1.2.x
Ranson, J H, Turner J W, Roses D F. “Respiratory complications in acute pancreatitis.” Annals of surgery vol. 179,5 (1974): 557-66. doi:10.1097/00000658-197405000-00006
Arvanitakis M, Delhaye M, De Maerteaere V et al. “Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis.” Gastroenterology vol. 126,3 (2004): 715-23. doi:10.1053/j.gastro.2003.12.006
Banks P A., Bellen T L, Dervenis C et al. "Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus." Gut 62.1 (2013): 102-111.
Working Group IAP/APA Acute Pancreatitis Guidelines. “IAP/APA evidence-based guidelines for the management of acute pancreatitis.” Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.] vol. 13,4 Suppl 2 (2013): e1-15. doi:10.1016/j.pan.2013.07.063
Wu, Bechien U, and Darwin L Conwell. “Acute pancreatitis part I: approach to early management.” Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association vol. 8,5 (2010): 410-6, quiz e56-8. doi:10.1016/j.cgh.2009.10.033
Xavier B O, Comas D R, Urrutia G. “Opioids for acute pancreatitis pain.” The Cochrane database of systematic reviews ,7 CD009179. 26 Jul. 2013, doi:10.1002/14651858.CD009179.pub2
Scott T, Baillie J, DeWitt J et al. “American College of Gastroenterology guideline: management of acute pancreatitis.” The American journal of gastroenterology vol. 108,9 (2013): 1400-15; 1416. doi:10.1038/ajg.2013.218
Vaughn VM, Shuster D, Rogers MAM, et al. Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review. Ann Intern Med. 2017 Jun 20;166(12):883-892. doi: 10.7326/M16-2533. Epub 2017 May 16. PMID: 28505667.
Heider, T R, Azeem S, Galanko JA et al. “The natural history of pancreatitis-induced splenic vein thrombosis.” Annals of surgery vol. 239,6 (2004): 876-80; discussion 880-2. doi:10.1097/01.sla.0000128685.74686.1e
Hernandez V, Pascual I, Almela P, et al. Recurrence of acute gallstone pancreatitis and relationship with cholecystectomy or endoscopic sphincterotomy. Am J Gastroenterol. 2004 Dec;99(12):2417-23. doi: 10.1111/j.1572-0241.2004.40896.x. PMID: 15571590.
