Acute Pancreatitis

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 Definition
• Acute pancreatitis is a clinical syndrome
resulting from acute inflammation and
destructive auto digestion of pancreas and
peri pancreatic tissue.
 Pathophysiology
• Insult leads to leakage of activated proteolytic
enzymes into pancreatic and peripancreatic
tissue leading to acute inflammatory reaction
 Etiology : most common
I GET SMASHED

• Idiopathic • Scorpion sting

• Hyper Ca, TG
• Gallstones (or other obstructive lesions)
• ERCP (5-10% of pts
• Etanol undergoing procedure)
• Trauma • Drugs (thiazides,
sulfonamides, ACE-I,
• Steroids NSAIDS, azathioprine)
• Mumps (& other viruses: CMV, EBV)
• Autoimmune (SLE, polyarteritis nodosa)
Ethanol and gallstones
account for 60-70% of
cases
Tityus trinitatis

Found in Central/
South America
and the Carribean
Less common
• Pancreas divisum
• Chinese liver fluke
• Ischemia (bypass surgery)
• Cystic fibrosis
 Clinical Presentations
• Severe epigastric pain  radiate to back
– Gradual or onset
– Sitting forward may relieve pain
• Nausea
• Vomiting
• Fever
• Jaundice
• Abdominal rigidity , local or generalized tenderness
• Tachycardia
• Shock

• Severity: mild(self limiting 1-2days) to death from pancreatic necrosis,

hemorrhage or sepsis.
• Relapsing acute pancreatitis may caused permanently damaged, resulting in
chronic pancreatitis or pancreas insufficiency.
 Grey turner: flank discoloration due to retroperitoneal bleed in pancreatic
necrosis
Cullen’s sign: periumbilical discoloration

• Cullen’s
Grey Turner
sign sign
 Investigations
• Serum amylase > 1000u/ml
– Levels start to fall within 1st 24-48 hours
– False –ve : acute on chronic (alcohol), hypertrigliceride
– False +ve : renal disease, salivary gland, acidemia.
• Serum lipase
– More sensitive and specific
• Other inflammatory marker: CRP > 150
• LFT : ALT increase in gallstone pancreatitis
• ABG – monitor oxygenation and acid base status
• Depending on severity may see:
–  Ca
– WBC
– BUN
–  Hct
–  glucose
• AXR
– No psoas shadow (retroperitoneal fluid increase)
– ‘sentinel-loop’ of proximal jejunum (solitary air-filled dilatation)
• Erect chest Xray
– Exclude other causes : perforation
• CT / MRI assess severity
• USG
– enlarged pancreas with stranding, abscess, fluid collections,
hemorrhage, necrosis or pseudocyst
• ERCP – if LFT worsen
Gall stone pancreatitis by ERCP
• Morbidity and mortality highest if necrosis
present (especially if necroctic area infected)
– Dual phase CT scan useful for initial eval to look
for necrosis
• However, necrosis may not be present for 48-72 hours
 Management
First 24 hours
• Symptomatic:
– Fluid Depleted (third space losses)
• IV access
• Aggressive fluid resiscitation
• Strict input/output balance
– Catheter, helps with input/output
– NG tube for vomiting/ileus
– Analgesia – Pethidine (75-100mg/4h), morphine (may cause
Oddi’s sphincter to contract more)
– Hourly pulse, BP, urine output
– Daily FBC, Urea and Electrolytes, Ca2+,Glucose, amylase, ABGs
 Treatment
• Antibiotics may reduce septic complications
• Do not forget alcohol withdrawal therapy if due to excess
alcohol
– Chlordiazepoxide 20mg qds PO
– Pabrinex IV (thiamine)
• If worsening, bring to ITU
• If suspected abscess formation and necrosis on CT 
parenteral nutrition, laparatomy and debridement.
• ERCP + gallstone removal : progressive jaundice
• PPI  stress ulcer
 Early complications
• Shock
• ARDS
• Acute Renal failure
• Hypocalcemia
• Hyperglycaemia
 Late complications (>1w)
• Pancreatic necrosis and pseudocyst
– Fluid in lesser sac
– + increase temperature, a mass, w/wo persistent increase
in amylase or lipase
– May resolve, mar need drainage (externally or
laparoscopically)
• Abscess – drain
• Bleeding
– Elastase eroding to major vessels (spleenic artery)
– Th/ embolization
• Thrombosis
– Splenic/gastroduodenal arteries
– Colic branches of superior messentric artery
– Causing bowel necrosis
• Fistula
– Normally close spontaneously
• Recurrent edematous pancreatitis
– Near total pancreatectomy
 Prognosis
• 85-90% mild, self-limited
– Usually resolves in 3-7 days
• 10-15% severe requiring ICU admission
– Mortality may approach 50% in severe cases
 Prognosis
• Many different scoring systems
– Ranson (alcohol induced pancreatitis)
• No association found with score, and mortality or length of
hospitalization
– APACHE II
– CT severity Index
• Recent studies show this to be most predictive of adverse outcomes
– CT score > 5 associated with 15x mortality rate
– Problem is 1 CT study showing this was conducted 72 hours after admission
(Ranson/Apache are 24 & 48 hours)
– Modified Glasgow (induced gallstone and alcohol)
• Atlanta Classification used to help compare various
scores (clinical research trials)
 Ranson Criteria
• During
Admission
first 48 hours
– Hematocrit
Age > 55 drop > 10%
– Serum
WBC > calcium
16,000 < 8
– Base
Glucose
deficit
> 200> 4.0
– Increase
LDH > 350in BUN > 5
– Fluid
AST >sequestration
250 > 6L
– Arterial PO2 < 60
5% mortality risk with <2 signs
15-20% mortality risk with 3-4 signs
40% mortality risk with 5-6 signs
99% mortality risk with >7 signs
 CT Severity Index
• Necrosis
CT Gradescore
– None
A is normal
(0 points)
(0 points)
– <B 1/3
is edematous
(2 points) pancreas (1 point)
– >C 1/3,
is B plus
< 1/2extrapancreatic
(4 points) changes (2 points)
– >D 1/2
is severe
(6 points)
extrapancreatic changes plus one fluid collection (3 points)
–
• TOTAL SCORE =
E is multiple or extensive fluid collections (4 points)

CT grade + Necrosis

0-1 = 0% mortality
2-3 = 3% mortality
4-6 = 6% mortality
7-10 = 17% mortality
 Modified Glasgow
PANCREAS
• 3 or more is severe, should be transferred to ITU/HDU

• PaO2 <8kPa
• Age >55yo
• Neutrophils WBC >15*109/L
• Calcium <2mmol/L
• Renal function urea > 16mmol/L
• Enzymes LDH > 600iu/L; AST > 200iu/L
• Albumin <32g/L (serum)
• Sugar blood glucose > 10mmol/L
The Santorini Consensus and World
Association Guidelines
• Available prognostic features which predict
complication in acute pancreatitis are
– clinical impression of severity
– Obesity
– APACHE II >8 in the first 24 hours of admission
– C reactive protein levels >150 mg/l
– Glasgow score 3 or more
– persisting organ failure after 48 hours in hospital