M Mir, S Manzoor, S Kursheed, B Bali, G Sheikh, M Bhat
acute pancreatitis, biliary ascariasis, gallstones, pancreas
M Mir, S Manzoor, S Kursheed, B Bali, G Sheikh, M Bhat. Clinicoetiological and Demographic Profile of Acute Pancreatitis in Kashmir Valley. The Internet Journal of Gastroenterology. 2012 Volume 11 Number 1.
Acute pancreatitis is an inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems.1Worldwide, gallstones are the most common cause accounting for approximately 45% of cases, alcohol being the second most common, accounting for 35% of cases.2Other rarer causes of include various drugs, trauma (accidental or iatrogenic), ERCP, metabolic abnormalities (hypertriglyceridemia, hypercalcemia), obstruction (tumors, pancreas divisum), infections (viral, parasitic, bacterial), and vascular abnormalities (emboli, ischemia, vasculitis).2Recently, researchers have described hereditary forms caused by a mutation in the trypsinogen-1 gene allowing premature activation of trypsinogen to trypsin.3Finally, about 10% of the cases are called idiopathic with no identifiable etiology.2The premature activation of trypsinogen to trypsin in the acinar cell in the pancreas is considered a possible key event in the development of acinar cell injury, leading to auto-digestion.1Usually, patients present with mild-to-severe epigastric pain, which in about 50% of cases radiates to the back and flanks, accompanied by nausea, vomiting, and fever.1
Material and methods
This prospective study was conducted in the Department of General Surgery, Government Medical College, Srinagar. The study included 150 consecutive patients of acute pancreatitis who were admitted over a period of five years from 1stJune 2006 to 31stMay 2011.A detailed history was taken and thorough clinical examination and investigations were performed on all patients to ascertain diagnosis with underlying etiology. Data collected was tabulated and subjected to appropriate statistical analysis. In each case of the study, history was taken and salient features were recorded especially with reference to pain, radiation and duration. Associated symptoms like nausea, vomiting, loss of appetite, jaundice, fever, abdominal distension were noted. Personal history with particular reference to alcohol intake, drug intake was taken into account. Relevant family history was also asked e.g. Dyslipidemia etc. Examination of each case was done with special reference to general condition. Vital signs, hemodynamic stability and abdominal status viz. tenderness, guarding, abdominal distension, epigastric fullness, presence of free fluid and bowel sounds were recorded. Cardiovascular system status, respiratory status and urine output of the patient were also observed. The clinical diagnosis of acute pancreatic and its etiology was ascertained by the findings on Ultrasonography findings, endoscopic retrograde cholangio-pancreatography (picture 1,2 and 3), magnetic resonance cholangio-pancreatography (image 4), and raised serum lipase/amylase levels. In our institution endoscopic Ultrasonography is not presently available, hence not done in any patient. The severity and morbidity/mortality was assessed by Computed tomography severity index (CTSI) as shown in picture 5 into group A of CTSI 0-3 (mild), group B of CTSI 4-6 (moderate) and group C of CTSI 7-10 (severe).
The majority of our patients were in the age range of 41-60 years and the average age of male patients was 47.71 years and of female patients was 51.48 years. Females had a predominance over males with male: female ratio of 1:1.38. Larger proportion of our patients was from rural areas of Kashmir with rural:urban ratio of 1.38:1. Biliary tract pathology was the predominant etiology in our study patients (table 1,4,5 and figure A). Most patients presented with history of pain abdomen and nausea, vomiting (table2). Tenderness and guarding of upper abdomen were the main clinical findings (table 3). Serum lipase and/or amylase was raised in only 33(22%) of cases (table 6 and figure B). As shown in table 7 Maximum complications were noted in Group C patients (91.67%) and minimum complications were seen in Group A patients (6.25%). Mortality was found to be highest among Group C patients (16.67%) indicating the severe nature of disease in them and no mortality was noted in Group A patients(table 8).
The table shows that most common etiological factor was found to be gall stones.
This table shows that pain abdomen was the most common symptom followed by nausea and vomiting.
The table shows that all our patients had epigastric tenderness at presentation.
In our study, as far as the sex ratio is concerned, females outnumbered males and the male to female ratio was 1:1.38 which conflicts with most of the studies. Balthazaar EJ4conducted a study in 1985 which had total of 83 patients with male : female ratio of 3.5:1, Balthazaar EJ5had 53 men and 35 women in his 1990 series with male to female ratio of 1.51:1, Antonio Carnovale’s6study of 1,135 patients had a male to female ratio of 1: 1.6 (431 males and 704 females), W Uhl7in his study of 302 patients has a male female ratio of 1.85:1, Study of Minguez M8had a male to female ratio of 1:1.4, K Choi9reported a male to female ratio of 1:1.1 and A C de Beaux10had a male to female ratio of 1.6:1 in his study. The possible explanation for this is the fact that alcoholism in males, which forms a major cause of pancreatitis in the western world, is found much less often as a cause of pancreatitis in this part of the world, because of a conservative society pattern and the female sex is at more risk of gallstone formation. Majority of patients in our study were in the age group of 41-60 yrs. The age range was 18-78yrs. Mean age for males was 47.714 years and for females was 51.483 years. Balthazaar EJ4in his 1985 series had age range of 17-79 years with a mean age of 45 years, Balthazaar EJ5had mean age of 52 years in his 1990 study and Antonio Carnovale6in his study had an age range of 18-93yrs with a median age of 61.5 yrs. In the study by W Uhl7the mean age was 50yrs. The age range in the study by A C de Beaux10was 11-93yrs with a median age of 53yrs. The mean age was 42.9±15.9 years (range: 18-80 years) in the study by Raghu M G
Hence we concluded in our study that the biliary causes are most common of acute pancreatitis and among which ascariasis is the second most common cause after the gallstones, which is preventable if transmission of ascariasis can be checked by sanitation barrier.