[Differential diagnosis and therapy of acute pancreatitis]

Acute pancreatitis is classified in an interstitial edematous pancreatitis and a hemorrhagic necrotizing pancreatitis comprising 80% and 20% respectively of all cases. 80% of acute pancreatitis are attributed to biliary and alcoholic origin whereas in more than 10% no etiology can be established comprising the idiopathic forms of acute pancreatitis. Clinical symptoms are rather unspecific resulting in a large number of abdominal and extraabdominal diseases that have to be considered regarding the differential diagnosis. Diagnosis is based on clinical examination, laboratory findings and ultrasound. However it has to be taken into account that a lack of abdominal symptoms and unaltered amylase and lipase levels may be present in spite of overt pancreatitis. As severe pancreatitis is associated with a steep increase in mortality the early identification of severe pancreatitis is crucial. Several prognostic scores like the Ranson-, Glasgow- and APACHE-II score were developed to achieve a higher sensitivity detecting transition to severe pancreatitis. In addition new prognostic serum parameters are applicable. A prophylactic antibiotic therapy is recommended in patients with sterile necrosis whereas an infected necrosis requires organ preserving necrosectomy and retroperitoneal lavage which can be done surgically or referring to new concepts endoscopically. Apart from renal and respiratory failure, necrosis, pseudocysts and pancreatic abscess are the main complications. In the presence of detected stones in the common bile tract ERCP in combination with stone extraction and papillotomy reduces morbidity and mortality in patients with biliary pancreatitis. Laparoscopic cholecystectomy should be performed as soon as the patient has recovered and preferably during the same hospital admission.