Patients suffering from acute or chronic pancreatitis may commonly present with the following symptomatology:

• Upper abdominal pain is associated with the retroperitoneal irritation caused by the pancreas inflammation.
• Referred pain at the back, spinal and dermatomal nerves of the back are subsequently irritated by any inflammation at the retroperitoneal spaces.
• Post prandial abdominal pain because the obstructed ampulla or sphincter of Oddi may cause pain after a fatty or heavy meal. 
• Nausea and vomiting, the digestive dysfunctions associated with pancreatitis can cause these common symptomatology.
• Severe prostration, pancreatic juices may spill out from the inflamed pancreas and irritate other areas of the peritoneum and retroperitoneum.
• Weight loss is a sign of a defective digestive process.
• Steatorrhea, obstructed pancreatic juices may retard the normal digestion of fats in the intestine; thus, it is disposed in the same unmetabolized form.

• Fever

  During this time, he experienced increasing fatigue, joint pain, and reported fevers and significant weight loss. An incidental serum amylase was found to be significantly elevated and remained elevated throughout his 2-month hospital stay. [ncbi.nlm.nih.gov]

  Acute pancreatitis Acute pancreatitis usually starts with pain that begins slowly or suddenly in your upper abdomen sometimes spreads to your back can be mild or severe may last for several days Other symptoms may include fever nausea and vomiting fast [niddk.nih.gov]

  Fever and ST decreases in the electrocardiogram are not uncommon. [revistanefrologia.com]

• Weight Loss

  Weight loss is a sign of a defective digestive process. Steatorrhea, obstructed pancreatic juices may retard the normal digestion of fats in the intestine; thus, it is disposed in the same unmetabolized form. [symptoma.com]

  During this time, he experienced increasing fatigue, joint pain, and reported fevers and significant weight loss. An incidental serum amylase was found to be significantly elevated and remained elevated throughout his 2-month hospital stay. [ncbi.nlm.nih.gov]

  Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support. [medlineplus.gov]

  For help in keeping your weight in check—and possibly protecting against pancreatitis—check out this guide to all-natural approaches to weight loss. [verywellhealth.com]

• Severe Pain

  This can result in severe pain common to acute pancreatitis and chronic symptoms associated with chronic pancreatitis. [naturalnews.com]

  The pain is typically exacerbated by movement and relieved by sitting, The symptoms of acute pancreatitis usually begins with severe pain in the upper abdomen. [best-home-remedies.com]

  Common symptoms are severe pain in the upper abdomen, nausea, and vomiting. Treatment is usually a few days in the hospital for intravenous (IV) fluids, antibiotics, and medicines to relieve pain. Chronic pancreatitis does not heal or improve. [medlineplus.gov]

• Sepsis

  Patients are at risk for sepsis and, ultimately, even death. The mortality rate approaches 100% if intervention and drainage are not undertaken for infected necrosis or abscess. [emedicine.medscape.com]

  Infection can sometimes lead to sepsis. In this illness, your body has a severe reaction to bacteria in your bloodstream. Sepsis can lead to shock. This reduces blood flow to your major organs. [cedars-sinai.org]

  Regular FBC, clotting and biochemical makers for sepsis, DIC and inflammatory. Regular CXR, CT / USS for complications. Timing of surgery is controversial ( more details in RCSI Guidelines 2005 [Local copy]). [emed.ie]

  One patient died from severe sepsis. Adverse events included severe abdominal pain and productive cutaneous fistulae (two patients). [ncbi.nlm.nih.gov]

  This increases the risk of sepsis, a severe bacterial infection that can affect the whole body. Sepsis can lead to multi-organ damage or failure. Severe acute pancreatitis can also cause hypovolemic shock. [medicalnewstoday.com]

• Asymptomatic

  We think this is an interesting case, because pancreatic extrarenal cysts are usually asymptomatic. [revistanefrologia.com]

  Cassano, Asymptomatic Hyperamylasemia and Hyperlipasemia Associated With Aripiprazole, Journal of Clinical Psychopharmacology, 10.1097/JCP.0b013e3181b3b379, 29, 5, (504-506), (2009). [doi.org]

  This dogma was subsequently challenged by 2 retrospective studies in which patients with smaller (ie, < 5 cm) asymptomatic pseudocysts rarely (< 10%) developed complications. [emedicine.medscape.com]

  The patient is now asymptomatic and on outpatient follow-up, with no signs of exocrine (triglycerides-mixed 13C test) or endocrine (HbA1c in normal levels) insufficiency. [scielo.isciii.es]

  Signs and symptoms[edit] Gallstones, regardless of size or number,[11] may be asymptomatic, even for years. [en.wikipedia.org]

• Pleural Effusion

  The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the “traditional” multifactorial scoring systems: Ranson's, Acute [doi.org]

  effusion) significantly increases the risk of pancreatic cancer. [gpnotebook.co.uk]

  Chronic pancreatitis can also give rise to specific complications including painful inflammatory mass and obstructed pancreatic duct, biliary or duodenal obstruction, haemorrhage, or accumulation of fluid in the abdomen (ascites) or chest (pleural effusion [nice.org.uk]

  Pancreatic ascites or pleural effusion may result. Pseudocysts or abscesses may also cause hollow viscus obstruction by compression of the surrounding structures, including the colon, stomach, duodenum, and the common bile duct. [emedicine.medscape.com]

  When the pleural effusion had not completely resolved following 3 weeks of treatment, another CT scan was performed, revealing that the pseudocyst was still present in the pancreas and causing the pleural effusion. [physio-pedia.com]

• Tachypnea

  When tachypnea and pending respiratory failure develops, intubation should be performed. Inpatient transfer Transfer patients with Ranson scores of 0-2 to a hospital floor. [emedicine.com]

  Respiratory insufficiency (e.g. significant tachypnea or increased work of breathing). Other organ failures (e.g. poor urine output, kidney injury, delirium, hypotension). [emcrit.org]

  The physical examination findings may be normal or reveal fever, hypotension, tachycardia, tachypnea, or diaphoresis. [aafp.org]

• Dyspnea

  The patient had no fever, abdominal pain, chest pain, dyspnea, or symptoms related to the urinary system, nor had she suffered from any recent trauma. [physio-pedia.com]

• Vomiting

  Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support. [medlineplus.gov]

  Nausea and vomiting, the digestive dysfunctions associated with pancreatitis can cause these common symptomatology. [symptoma.com]

  Acute pancreatitis Acute pancreatitis usually starts with pain that begins slowly or suddenly in your upper abdomen sometimes spreads to your back can be mild or severe may last for several days Other symptoms may include fever nausea and vomiting fast [niddk.nih.gov]

• Abdominal Pain

  Less common causes include: Viral infection, abdominal trauma, hereditary, and diagnostic procedures like ERCP. Symptoms Upper abdominal pain is a very common presenting sign of pancreatitis. [symptoma.com]

  Recurrent abdominal pain (intermittent or constant) Greasy or oily stools (steatorrhea) Weight loss What Should I Do If I Think I Have Pancreatitis? If you are experiencing severe abdominal pain, call your doctor or go to the nearest emergency room. [patients.gi.org]

  Signs and symptoms include abdominal pain, malabsorption and diabetes mellitus Inflammation of the pancreas that is characterized by recurring or persistent abdominal pain with or without steatorrhea or diabetes mellitus. [icd9data.com]

  The patient reported nausea, vomiting, severe abdominal pain, and loose stools. [revistanefrologia.com]

  Chronic pancreatitis signs and symptoms include: Abdominal pain - this can vary from sudden and severe to constant with episodes of worsening abdominal pain; Unexplained weight loss; Fatty stool and diarrhea. [barnesjewish.org]

• Nausea

  Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support. [medlineplus.gov]

  Nausea and vomiting, the digestive dysfunctions associated with pancreatitis can cause these common symptomatology. [symptoma.com]

  Acute pancreatitis Acute pancreatitis usually starts with pain that begins slowly or suddenly in your upper abdomen sometimes spreads to your back can be mild or severe may last for several days Other symptoms may include fever nausea and vomiting fast [niddk.nih.gov]

• Upper Abdominal Pain

  Less common causes include: Viral infection, abdominal trauma, hereditary, and diagnostic procedures like ERCP. Symptoms Upper abdominal pain is a very common presenting sign of pancreatitis. [symptoma.com]

  People with chronic pancreatitis have recurrent or even continuous upper abdominal pain, or might have repeated episodes of acute pancreatitis. Treatment options for pancreatitis include fasting, medications or surgery. [healthdirect.gov.au]

  Acute pancreatitis should be suspected in patients with severe acute upper abdominal pain but requires biochemical or radiologic evidence to establish the diagnosis. [web.archive.org]

  The signs and symptoms of acute pancreatitis include: Upper abdominal pain Abdominal pain that radiates to your back Abdominal pain that feels worse after eating Fever Rapid pulse Nausea Vomiting Tenderness when touching the abdomen Symptoms of chronic [dhawy.com]

  Signs and symptoms of acute pancreatitis include intense upper abdominal pain often times radiating through to the back (major symptom), nausea, vomiting, fever, rapid heart rate, abdominal tenderness, and sometimes jaundice and even shock. [pancreatica.org]

• Diarrhea

  Clinical assessment and management in patients with infectious colitis The patients visited our emergency department because of severe abdominal pain, diarrhea, and/or vomiting for several days. [ncbi.nlm.nih.gov]

  As a result, people with chronic pancreatitis can lose weight, experience diarrhea, become malnourished with vitamin deficiencies and develop diabetes. To continue reading this article, you must login. [health.harvard.edu]

  Once digestive problems are treated, people often gain weight and their diarrhea improves. Diabetes caused by chronic pancreatitis almost always requires treatment with insulin. [drugs.com]

  You dose the enzymes so the diarrhea stops. Once that stops, you know the enzymes are working. Patients really can't take too much of those.” [acpinternist.org]

  Other symptoms of chronic pancreatitis include: Nausea Vomiting (vomit may be yellowish, greenish or brownish) Diarrhea and oily bowel movements Trouble digesting food and poor growth Diabetes mellitus Jaundice (yellow discoloration of the skin) In some [cincinnatichildrens.org]

• Tachycardia

  Typical signs include epigastric tenderness, fever, and tachycardia. Elevated serum amylase and lipase concentration supports, but is not pathognomonic for, the diagnosis of acute pancreatitis. [bestpractice.bmj.com]

  Ventricular tachycardia/fibrillation. Cardiac arrest. Acute myocardial infarction. Pulmonary Respiratory rate ≤5 per minute or ≥50 per minute. [aafp.org]

  Common symptoms of acute pancreatitis can include: sudden severe upper abdominal pain (often referred to as epigastric pain) severe pain that might also be felt in the back nausea and vomiting diarrhea fever and chills racing of the heart (also known as tachycardia [muschealth.org]

  Signs and symptoms[edit] Common[edit] severe epigastric pain (upper abdominal pain) radiating to the back in 50% of cases nausea vomiting loss of appetite fever chills (shivering) hemodynamic instability, including shock tachycardia (rapid heartbeat) [en.wikipedia.org]

• Jaundice

  Detection and diagnosis When making a diagnosis, the doctor checks for signs of jaundice, weakness, emaciation, diarrhea and/or foul-smelling stool. [gwhospital.com]

  Detection and Diagnosis When making a diagnosis, the doctor checks for signs of jaundice, weakness, emaciation, diarrhea and/or foul-smelling stool. [aikenregional.com]

  Symptoms may be attributable to the failure of: biliary outflow: jaundice exocrine function: malabsorption endocrine function: diabetes Acute pancreatitis and chronic pancreatitis are assumed to be different disease processes, and most cases of acute [radiopaedia.org]

  ERCP (an endoscopy test) to place a stent in the bile duct to unblock it to relieve jaundice, can trigger acute pancreatitis. [pancreaticcanceraction.org]

  Nausea and vomiting Raised blood pressure Dehydration Internal bleeding Elevated heart rate and breathing rate Fever Jaundice Weight loss and loss of appetite Chronic pancreatitis may also lead to diabetes and even pancreatic cancer Causes The majority [news-medical.net]

• Sweating

  They may also have nausea, vomiting, fevers, sweats and have a tender abdomen. They need treatment in hospital. [healthdirect.gov.au]

  Gene OMIM (Gene) Associated diseases (OMIM) Inheritance CentoMD® exclusive variant numbers (++) CFTR 602421 hereditary pancreatitis; protection against chronic Pancreatitis; Bronchiectasis with or without elevated sweat chloride type 1; cystic fibrosis [centogene.com]

  Other signs and symptoms of acute pancreatitis includes nausea and vomiting, f ever, excessive gas, upper abdominal pain described as burning or stabbing, fever, sweating, hypertension, muscle aches, and abnormal, fatty stools. 2. [best-home-remedies.com]

  Common symptoms of an acute attack include: Severe abdominal pain, often spreading through into the back Bloating Fever Sweating Nausea Vomiting Collapse. [web.archive.org]

  Becomes constant and more severe, lasting for several days May be worse when lying flat on the back May spread (radiate) to the back or below the left shoulder blade People with acute pancreatitis often look ill and have a fever, nausea, vomiting, and sweating [pennmedicine.org]

• Grey Turner's Sign

  What is Cullen and Grey-Turner's Sign? Cullen's Sign is a bluish discoloration around the belly button, whereas Grey-Turner's Sign is bluish discoloration found on the flanks of the abdomen. They are due to retroperitoneal bleeding. [youtube.com]

  (Rare) signs of hemorrhage on the physical exam include: Cullen sign : periumbilical bruising Grey-Turner sign : flank bruising There continues to be debate over the precipitating factor leading to acute pancreatitis, with duct occlusion being an important [radiopaedia.org]

  […] of fatal disease nausea and vomiting anorexia fever and chills dyspnoea steatorrhoea Examination Appearance may vary from well to seriously ill SIRS: tachycardia, tachypnoea, pyrexia jaundice evidence of retroperitoneal haemorrhage ( flank echymosis (Grey-Turner [lifeinthefastlane.com]

  […] nausea and vomiting anorexia fever and chills dyspnoea steatorrhoea Examination Appearance may vary from well to seriously ill SIRS: tachycardia, tachypnoea, pyrexia jaundice evidence of retroperitoneal haemorrhage (<1%, poor prognosis) flank echymosis (Grey-Turner [litfl.com]

• Shoulder Pain

  […] or left shoulder pain Because symptoms of chronic pancreatitis resemble those of other illnesses, diagnosing it can be challenging. [cincinnatichildrens.org]

  […] or left shoulder pain Short-term symptoms can include dehydration and low blood pressure. [kidshealth.org]

• Hyperactivity

  » CPR Resource Center » School Lunches » Attention deficit/hyperactivity disorder (ADHD) in children » See All In Case You Missed It: Get the latest news on health and wellness delivered to your inbox! Licensing [health.harvard.edu]

• Dark Urine

  Symptoms of pancreatitis include: sudden, very painful mid-epigastric or left upper quadrant which can be felt in the back as well, fever, increased heart rate, decreased blood pressure, Cullen's sign, Grey-Turner's sign, hyperglycemia, dark-urine, jaundice [youtube.com]

  After the onset of pain, jaundice and dark urine appeared. Amylase greater than 894 U/L, lipase = 2653 U/L, AST = 1345 U/L, ALT = 1876 U/L, and GGT = 678 U/L. Bilirubin was high with a greater direct fraction. [actagastro.org]

  […] green or brown or chalk white and are oval, usually solitary, between 2 and 3 cm long, each often having a tiny, dark, central spot. [en.wikipedia.org]

  […] acute pancreatitis because the symptoms are similar, gallstones, and neoplastic or inflammatory masses.[2][4] Case Reports Patient Demographics: Sixty-year-old male who was admitted to a hospital in October 2001 Chief Complaints: Abdominal pain and dark [physio-pedia.com]

The following diagnostic modalities and tests are being used to work up patients with pancreatitis:

• Alkaline phosphatase: A positive blood test of an elevated pancreatic enzyme alkaline phosphatase is very suggestive of a pancreatitis.
• Stool analysis of fats: Patients with chronic pancreatitis are usually analyzed with degree of fats in the stools which is indicative of a defective lipid metabolism and absorption.
• Abdominal and endoscopic Ultrasound is used to determine degree of obstruction in the bile duct system and the presence of obstructive bile stones.
• Computerized tomography (CT scan) will identify the size and location of gallstones, and the extent of pancreatic inflammation [8].
• Magnetic resonance imaging (MRI) will elucidate a more detailed view of the pancreas and the biliary tree.

• Pleural Effusion

  The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the “traditional” multifactorial scoring systems: Ranson's, Acute [doi.org]

  effusion) significantly increases the risk of pancreatic cancer. [gpnotebook.co.uk]

  Chronic pancreatitis can also give rise to specific complications including painful inflammatory mass and obstructed pancreatic duct, biliary or duodenal obstruction, haemorrhage, or accumulation of fluid in the abdomen (ascites) or chest (pleural effusion [nice.org.uk]

  Pancreatic ascites or pleural effusion may result. Pseudocysts or abscesses may also cause hollow viscus obstruction by compression of the surrounding structures, including the colon, stomach, duodenum, and the common bile duct. [emedicine.medscape.com]

  When the pleural effusion had not completely resolved following 3 weeks of treatment, another CT scan was performed, revealing that the pseudocyst was still present in the pancreas and causing the pleural effusion. [physio-pedia.com]

Patients initially diagnosed with pancreatitis are usually hospitalized for stabilization and treatment. Initially, patients are asked to fast (NPO) until the pancreatic inflammation subsides. When the pancreatic inflammation is controlled, patients may be started on clear liquids and low fat diets [9]. Patients are placed in intravenous resuscitation to address dehydration and institute Intravenous analgesics to control pain symptoms. Non-medical approach to pancreatitis include biliary repair of obstruction using ERCP, cholecystectomy if bile stones are formed from the gallbladder [10], and pancreatic drainage of fluids and necrotic debris.

A great majority of pancreatitis cases is self-limiting without the need for surgery and medical interventions. Although, severe cases may lead to significant morbidity and mortality in 10 to 15% of cases. Patients with primary biliary problems are more associated with a worse prognosis compared to the alcohol induced form which has a lower morbidity rating. The advances in the medical health care delivery and supportive management have significantly reduced the morbidity and mortality ratings of pancreatitis in general. However, in patients seen in the emergency room presenting with organ failure, the mortality rate will rise to 30% in these cases [6].

The following systemic manifestations are among the serious systemic manifestations of pancreatitis: Acute renal failure, acute respiratory distress syndrome (ARDS), cardiac insufficiency, hypovolemic shock, and hemorrhage. An increase in the neutrophil lymphocytic ratio (NLR) observed within the first 48 hours of pancreatitis is associated with a severe form of pancreatitis and a poor prognosis [7].

Pancreatitis is commonly caused by obstructive biliary stones and chronic alcoholic intake [1]. An estimated 10-30% of pancreatitis cases have an unknown or idiopathic etiology. Some diagnostic modalities like the endoscopic retrograde cholangio-pancreatography (ERCP) can cause pancreatitis among patients after the procedure. The pathology in this complication is the eminent dysfunction of the sphincter of Oddi during and after the procedure. Blunt abdominal trauma and penetrating injuries to the abdomen can cause direct damage to the pancreatic gland and cause pancreatitis, this is seen in approximately 1.5% of cases. Less common causes of pancreatitis like viral infection has been documented especially with mumps, coxsackie, cytomegalovirus, Epstein-Barr, varicella, rubella and hepatitis virus infections. Accounting for 2% of cases of pancreatitis are drug-induced, the following drugs are proven to cause pancreatitis among susceptible patients:

• Azathioprine
• Chlorthiazide and Hydrochlorthiazide
• Metronidazole
• Methyldopa
• Piroxicam
• Cimetidine
• Corticosteroids
• Nitrofurantoin
• Estrogens
• Sulfonamides 

In the United States, there is an estimated 40 cases of pancreatitis per 100,000 adults per year [2]. In 1998 alone, an estimated 183,000 cases of acute pancreatitis have been admitted in the hospitals, and the trend has continually increased in the following decades [3]. The worldwide incidence of pancreatitis is between 5 to 80 cases per 100,000 population, with the highest incidence noted in the United States and Finland [4]. In the United States, the majority of cases of pancreatitis is alcohol induced while European countries and Hong Kong has a predominance of microlithiasis induced type of pancreatitis.

The relative median age of onset for pancreatitis is dependent on its etiology [5]. For example alcoholic pancreatitis which peaks at 39 years old, biliary pathology which are more prone by 69 years old, and drug induced types of pancreatitis that occurs at a mean age of 42. There is a male predominance over its female counterpart for pancreatitis. A racial predilection among the black population is notably observed over the light skinned races.

During the process of normal digestion, the inactivated enzymes from the exocrine pancreas traverse to the intestinal lumen where they are activated to digest the food contents of the small intestine. In the actual pancreatitis, these enzymes are activated within the gland causing cellular autodigestion, irritation, and inflammations. Acute inflammation will convey the usual signs and symptoms of acute pancreatitis. When recurrent bouts of acute pancreatic inflammation occurs in a long standing period, this is now referred to as chronic pancreatitis. The post inflammatory scarring of the pancreatic tissues will cause a subsequent loss of function of the gland causing digestion problems and diabetes consequently.

One of the corner stone in the control of pancreatitis is the eventual control of alcohol dependence. Smoking can also impair digestion and advertently cause pancreatitis; thus, abstinence from this vice can prevent the inflammation. The dietary modifications of a low fat diet can reduce the incidence of pancreatitis, and reduce its digestive menace. Adequate hydration can help keep the pancreas hydrated and safe.

Pancreatitis is a clinical disease characterized by the inflammation of the exocrine pancreas which may lead to autodigestion of the gland itself. Pancreatitis is generally classified as acute which presents suddenly and resolves in days, and chronic which presents in the course of many years. In most mild cases of pancreatitis, the inflammation subsides spontaneously even without treatment but in some occasion pancreatitis can be very severe that it can cause life threatening complications.

Definition

Pancreatitis is a clinical disease characterized by the inflammation of the exocrine pancreas which may lead to auto digestion of the gland. 

Cause

Pancreatitis is primarily caused by alcohol binge drinking and biliary microlithiasis obstructions. Less common causes include: Viral infection, abdominal trauma, hereditary, and diagnostic procedures like ERCP.

Symptoms

Upper abdominal pain is a very common presenting sign of pancreatitis. Other signs includes nausea and vomiting, prostration, steatorrhea and weight loss.

Diagnosis

Blood test with alkaline phosphatase, ERCP, Ultrasound, CT scan and MRI.

Treatment and follow-up

Patients are asked to fast with intravenous fluid support. Pain management and surgical correction of underlying pathology. Patients are advised to refrain from alcohol intake to prevent recurrence.

1. Whitcomb DC, Yadav D, Adam S, et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008; 8(4-5):520-31.
2. Granger J, Remick D. Acute pancreatitis: models, markers, and mediators. Shock. Dec 2005; 24 Suppl 1:45-51.
3. Singla A, Csikesz NG, Simons JP, Li YF, Ng SC, Tseng JF, et al. National hospital volume in acute pancreatitis: analysis of the Nationwide Inpatient Sample 1998-2006. HPB (Oxford). Aug 2009; 11(5):391-7.
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5. Morinville VD, Barmada MM, Lowe ME. Increasing incidence of acute pancreatitis at an American pediatric tertiary care center: is greater awareness among physicians responsible? Pancreas. Jan 2010; 39(1):5-8.
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9. Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin Gastroenterol Hepatol. Aug 2007; 5(8):946-51.
10. Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. Apr 2010; 251(4):615-9.