Acute pancreatitis. A review with an emphasis on new developments.

The spectrum of acute pancreatitis can range from mild and self-limited to severe and fatal. A number of aspects of the condition remain poorly understood or controversial, although recent advances have improved our understanding in many areas. A substantial number of cases of "idiopathic" acute pancreatitis may be caused by occult biliary microlithiasis. The mechanism by which enzymes and bioactive substances become activated within the pancreas is a major unanswered question in acute pancreatitis; however, recent studies suggest that lysosomal enzymes within the pancreatic acinar cell may play a role. A recent refinement in computed tomography, contrast-enhanced dynamic pancreatography, has shown itself to be an extremely useful tool for detecting pancreatic necrosis and its extent, which correlates with the severity of pancreatitis and is useful in identifying patients who may have pancreatic infection and other complications. The management of acute pancreatitis includes supportive measures, observation for development of complications, and the identification of the cause of pancreatitis to prevent recurrences. Specific treatments introduced with the goal of halting the cycle of pancreatic autodigestion and benefiting the course of pancreatitis have generally proved ineffective. Early aggressive treatment of biliary pancreatitis remains controversial; however, endoscopic sphincterotomy may be helpful in more severe cases of biliary pancreatitis if there is no clinical improvement over 48 to 72 hours. Computed tomography-guided percutaneous needle aspiration appears to be a safe and reliable method for diagnosing infected pancreatic necrosis, pancreatic abscess, and infected pancreatic fluid collections.