Acute Pancreatitis
Definition
• Pancreatitis is an inflammatory process in which pancreatic enzymes
autodigest the gland.
• Acute : The gland heals without any impairment of function or any
morphologic changes.
• Chronic : Pancreatitis that recur intermittently, contributing to the
functional and morphologic loss of the gland.
Etiology
@article{PrezMateo2006HowWP, title={How we predict the
etiology of acute pancreatitis.}, author={Miguel
P{\'e}rez-Mateo}, journal={JOP : Journal of the
pancreas}, year={2006}, volume={7 3}, pages={ 257-61 } }
Demographic
The following are median ages of onset for various etiologies:
• Alcohol-related - 39 years
• Biliary tract–related - 69 years
• Trauma-related - 66 years
Sex-related demographic :
• Drug-induced etiology - 42 years
• Affects males more often than
• ERCP-related - 58 years females.
• AIDS-related - 31 years • In males, the etiology is more often
related to alcohol; in females, it is
• Vasculitis-related - 36 years more often related to biliary tract
disease.
Presentation
History :
• Abdominal pain in the upper abdomen, radiates through the abdomen to the back,
which is characteristically dull, boring, and steady.
• Discomfort improves with the patient sitting up and bending forward
• Nausea and vomiting along with accompanying anorexia
• Diarrhea
• Recent operative or other invasive procedures (eg, endoscopic retrograde
cholangiopancreatography [ERCP]) or family history of hypertriglyceridemia.
• History of previous biliary colic and binge alcohol consumption.
Presentation
Physical Examination
• Fever (76%) and tachycardia (65%)
• Abdominal tenderness, muscular guarding (68%), and distention (65%);
diminished or absent bowel sounds
• Jaundice (28%)
• Dyspnea (10%), pleural effusion, or acute respiratory distress syndrome
(ARDS); tachypnea may occur; lung auscultation may reveal basilar
rales, especially in the left lung
• In the extremities, muscular spasm may be noted secondary to
hypocalcemia
Presentation
Uncommon physical findings are
associated with severe necrotizing
pancreatitis:
• The Cullen sign : a bluish
discoloration around the umbilicus
• The Grey-Turner sign : a reddish-
brown discoloration along the
flanks resulting from
retroperitoneal blood dissecting
along tissue planes.
Workup
Laboratory studies
• White blood cell [WBC] count higher than 12,000/µL with the differential being
shifted toward the segmented polymorphonuclear (PMN) cells
• Serum amylase levels of amylase or lipase 3 times the upper limit of normal.
Levels of both amylase and lipase peak within the first 24 hours of symptoms.
Lipase has a slightly longer half-life and its abnormalities may support the
diagnosis if a delay occurs between the pain episode and the time the patient
seeks medical attention.
• Alkaline phosphatase, total bilirubin, aspartate aminotransferase (AST), and
alanine aminotransferase (ALT) levels to search for evidence of gallstone
pancreatitis.
Workup
Imaging
• Abdominal ultrasonography low sensitivity in detecting gallstones pancreatitis
• Contrast-enhanced computed tomography (CT), plays an essential role in
evaluation of the progression to severe acute pancreatitis with associated
complications.
CT severity
score
(Balthazar
score)
Acute Pancreatitis: Revised Atlanta Classification
Management
Nicolien J. Schepers, Marc G.H. Besselink, Hjalmar C. van Santvoort, Olaf J. Bakker, Marco J. Bruno,
Early management of acute pancreatitis,
Best Practice & Research Clinical Gastroenterology,
Volume 27, Issue 5,
2013,
Pages 727-743,
Antibiotics
• Antibiotics are always recommended to treat infected severe acute
pancreatitis.
• In patients with infected necrosis, the spectrum of empirical antibiotic
regimen should include both aerobic and anaerobic Gram-negative
and Gram-positive microorganisms.
Percutaneus/ Endoscopic drainage
- Emergency : Clinical deterioration with signs or strong suspicion of infected necrotizing
pancreatitis
- After 4 weeks after the onset of the disease:
On-going organ failure without sign of infected necrosis
On-going gastric outlet, biliary, or intestinal obstruction due to a large walled off necrotic
collection
Disconnected duct syndrome
Symptomatic or growing pseudocyst
- After 8 weeks after the onset of the disease:
On-going pain and/or discomfort
Surgical Intervention
• As a continuum in a step-up approach after percutaneous/endoscopic
procedure with the same indications
• Abdominal compartment syndrome
• Acute on-going bleeding when endovascular approach is unsuccessful
• Bowel ischaemia or acute necrotizing cholecystitis during acute
pancreatitis
• Bowel fistula extending into a peripancreatic collection
Sepsis Predictor and 1-hour
sepsis bundle
SOFA Score
qSOFA
