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Acute Pancreatitis

Acute Pancreatitis


Acute Pancreatitis is inflammation of the pancreas resulting from prematurely activated pancreatic digestive enzymes that invoke pancreatic tissue autodigestion.


Most patients with acute pancreatitis have mild to moderate disease but up to 25% have severe disease. There are two forms of acute pancreatitis, mild and severe:


  1. Mild acute pancreatitis is most common and responds well to supportive treatment.


  1. Severe acute pancreatitis (necrotizing pancreatitis) has significant morbidity and mortality



Acute Pancreatitis       Thursday, May 19, 2022




  • Alcohol abuse (40%)


  • Gallstones (40%)—the gallstone passes into the bile duct and blocks the ampulla of Vater


  • Post-ERCP—pancreatitis occurs in up to 10% of patients undergoing ERCP


  • Viral infections (e.g., mumps, Coxsackievirus B)


  • Drugs—sulfonamides, thiazide diuretics, furosemide, estrogens, HIV medications,


  • and many other drugs have been implicated


  • Postoperative complications (high mortality rate)


  • Scorpion bites


  • Pancreas divisum (controversial)


  • Pancreatic cancer


  • Hypertriglyceridemia, hypercalcemia


  • Uremia


  • Blunt abdominal trauma (most common cause of pancreatitis in children)



Acute Pancreatitis       Thursday, May 19, 2022



  • Quick HIT


Most cases of acute pancreatitis are due to alcohol or gallstones (70% to 80%) and Recurrences are common in alcoholic pancreatitis



Clinical features




  • Abdominal pain, usually in the epigastric region


  • May radiate to back (50% of patients)


  • Often steady, dull, and severe; worse when supine and after meals


  • Nausea and vomiting, anorexia





  • Low-grade fever, tachycardia, hypotension, leukocytosis


  • Epigastric tenderness, abdominal distention


  • Decreased or absent bowel sounds indicate partial ileus


  • The following signs are seen with hemorrhagic pancreatitis as blood tracks along fascial planes:


  • Grey Turner sign (flank ecchymoses)


  • Cullen sign (periumbilical ecchymoses)


  • Fox sign (ecchymosis of inguinal ligament)




Acute Pancreatitis       Thursday, May 19, 2022





  1. Laboratory studies


  • Serum amylase is the most common test, but many conditions cause hyperamylasemia (nonspecific) and its absence does not rule out acute pancreatitis (nonsensitive). However, if levels are more than five times the upper limit of normal, there is a high specificity for acute pancreatitis.


  • Serum lipase—more specific for pancreatitis than amylase.


  • LFTs—to identify cause (gallstone pancreatitis).


  • Hyperglycemia, hypoxemia, and leukocytosis may also be present.


  • Order the following for assessment of prognosis (see Table 3-4— Ranson criteria): glucose, calcium, hematocrit, BUN, arterial blood gas (PaO2, base deficit), LDH, AST, WBC count.


  1. Abdominal radiograph


  • Has a limited role in the diagnosis of acute pancreatitis.


  • More helpful in ruling out other diagnoses, such as intestinal perforation (free air). The presence of calcifications can suggest chronic pancreatitis.


  • In some cases, one may see a sentinel loop (area of air-filled bowel usually in LUQ, which is a sign of localized ileus) or a colon cut-off sign (air-filledsegment of transverse colon abruptly ending or “cutting off” at the region of pancreatic inflammation).


  1. Abdominal ultrasound


  • Can help in identifying cause of pancreatitis (e.g., gallstones)


  • Useful for following up pseudocysts or abscesses


  1. CT scan of the abdomen


  • Most accurate test for diagnosis of acute pancreatitis and for identifying complications of the disease


  • Indicated in patients with severe acute pancreatitis


  1. ERCP – Endoscopic Retrograde Cholangio Pancreatography




  • Severe gallstone pancreatitis with biliary obstruction


  • To identify uncommon causes of acute pancreatitis if disease is recurrent


  • Quick HIT


The diagnosis of acute pancreatitis is usually made based on clinical presentation. Laboratory studies are supportive, and CT scan is confirmatory.




  1. Pancreatic necrosis (may be sterile or infected)


  • Sterile pancreatic necrosis—infection may develop, but half of all cases resolve spontaneously. These patients should be monitored closely in an ICU. Prophylactic antibiotics are controversial but if necrosis involves more than 30% of pancreas, antibiotics should be strongly considered.


  • Infected pancreatic necrosis—has high mortality rate (results in multiple organ failure in 50% of cases); surgical débridement and antibiotics indicated.


  • The only way to distinguish sterile from infected necrosis is via CT-guided percutaneous aspiration with Gram stain/culture of the aspirate


  1. Pancreatic pseudocyst


  • Encapsulated fluid collection that appears 2 to 3 weeks after an acute attack unlike a true cyst, it lacks an epithelial lining


  • Complications of untreated pseudocysts include rupture, infection, gastric outlet obstruction, fistula, hemorrhage into cyst, and pancreatic ascites. It may impinge on adjacent abdominal organs (e.g., duodenum, stomach, transverse colon) if large enough; or if located in the head of the pancreas, it may cause compression of the CBD.


  • Diagnosis: CT scan is the study of choice.


  • Treatment


  • Cysts <5 cm: observation


  • Cysts >5 cm: drain either percutaneously or surgically
  1. Hemorrhagic pancreatitis


  • Characterized by Cullen sign, Grey Turner sign, and Fox sign


  • CT scan with IV contrast is the study of choice


  1. Adult respiratory distress syndrome—a life-threatening complication with high mortality rate


  1. Pancreatic ascites/pleural effusion—the most common cause is inflammation of peritoneal surfaces



  • Ascending cholangitis—due to gallstone in ampulla of Vater, leading to infection of biliary tract; see section on cholangitis


  • Pancreatic abscess (rare)—develops over 4 to 6 weeks and is less life-threatening than infected pancreatic necrosis


  • Acute Respiratory Distress symptoms




  1. Patients with mild acute pancreatitis:


  • Bowel rest (NPO)—goal is to rest the pancreas.


  • IV fluids—patients may have severe intravascular volume depletion. Correct electrolyte abnormalities.


  • Pain control, but be cautious in giving narcotics. Fentanyl and meperidine preferred over morphine which causes an increase in sphincter of Oddi pressure.


  • Nasogastric tube if severe nausea/vomiting or ileus present; routine use is controversial.


  • Patients with severe pancreatitis should be admitted to the ICU. Early enteral nutrition in the first 72 hours is recommended through a nasojejunal tube. If the severe acute pancreatitis has not resolved in a few days, supplemental parenteral nutrition should be started. If more than 30% of the pancreas is necrosed, prophylactic antibiotics (imipenem) should be considered to prevent infection (which has high morbidity and mortality).


  • Quick HIT


Most patients with acute pancreatitis respond to supportive care of pain control,bowel rest, IV fluids, and correction of electrolyte abnormalities and do not require any further therapy