LIVER, PANCREAS AND

BILIARY TRACT PROBLEMS

RESEARCH JOURNAL
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
By: ELAINE FRANCES M. ILLO, RM,
GRADUATE SCHOOL RN
 PATHOLOGICAL ACUTE INFLAMMATION
IN CHRONIC PANCREATITIS
by: Pavankumar Vijayaraj1, Biju Pottakkat1, Raja Kalayarasan1, Sandip
Chandrasekar1, Surinder Kumar Verma2
Published: July 04, 2019
https://pancreas.imedpub.com/pathological-acute-inflammation-in-
chronic-pancreatitis.php?aid=25079
ABSTRACT
Mechanism of pain in Chronic Pancreatitis is not fully understood. Recurrent acute
inflammation is one of the proposed hypotheses for pain in chronic pancreatitis. The
actual incidence and prevalence of ongoing acute inflammation in chronic pancreatitis
have been under-noticed in literature. This study aims to examine the prevalence of acute
pancreatic inflammation in chronic pancreatitis patients. Methods: Fifty patients who
underwent surgery for chronic pancreatitis were analyzed. Those with clinical,
biochemical or radiological features of acute on chronic pancreatitis were excluded. Intra
operative fine needle aspiration cytology was taken from the head and body of pancreas.
Pancreatic tissue was sent for histopathological examination in all patients. Results:
Intraoperative fine needle aspiration cytology from pancreas showed features of acute
inflammation in twenty 23 (46%) cases. Biopsy from pancreas showed features of acute
inflammation in 12 patients (24%). 30/50 (60%) patients had some features of acute
inflammation in either fine needle aspiration cytology or biopsy. 
CONCLUSION
Significant proportion of patients with chronic pancreatitis has pathological
features of acute inflammation in pancreas despite clinical, biochemical and
radiological features showing no evidence of acute pancreatitis. Ongoing
pathological acute inflammatory process in the pancreas might be a major
cause for initiation and progression of chronic fibrosis in chronic pancreatitis.
 2019 WSES GUIDELINES FOR THE
MANAGEMENT OF SEVERE ACUTE
PANCREATITIS
by: Ari Leppäniemi, et. al.
Published: 13 June 2019
https://wjes.biomedcentral.com/articles/10.1186/s13017-
019-0247-0
ABSTRACT
Although most patients with acute pancreatitis have the mild form of the disease, about
20–30% develops a severe form, often associated with single or multiple organ dysfunction
requiring intensive care. Identifying the severe form early is one of the major challenges in
managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis
occurs in about 20–40% of patients with severe acute pancreatitis, and is associated with
worsening organ dysfunctions. While most patients with sterile necrosis can be managed
nonoperatively, patients with infected necrosis usually require an intervention that can be
percutaneous, endoscopic, or open surgical. These guidelines present evidence-based
international consensus statements on the management of severe acute pancreatitis from
collaboration of a panel of experts meeting during the World Congress of Emergency
Surgery in June 27–30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall
under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive
Care Unit, Surgical and operative management, and Open abdomen. 
DISCUSSION
Acute pancreatitis (AP) represents a disease characterized by acute
inflammation of the pancreas and histologically acinar cell destruction. The
diagnosis of AP requires at least the presence of two of the three following
criteria: (i) abdominal pain consistent with the disease, (ii) biochemical
evidence of pancreatitis (serum amylase and/or lipase greater than three times
the upper limit of normal), and (iii) characteristic findings from abdominal
imaging.
Most patients (80–85%) will develop a mild disease course (self-limited,
mortality < 1–3%), but around 20% will have a moderate or severe episode of
AP, with a mortality rate from 13 to 35%. Thus, it is important to diagnose (or
better predict) an episode of severe acute pancreatitis (SAP), and to identify
the patients with high risk of developing complications.
DISCUSSION
On admission, the etiology of AP should be determined, to project the need of definitive
treatment (e.g., gallstone disease) and to avoid recurrence (e.g., alcohol intake,
hypertriglyceridemia). The treatment and follow-up depend on the etiology of the AP. A
transabdominal US should be performed on admission (to perform cholecystectomy for biliary
pancreatitis when appropriate). Almost all the AP guidelines worldwide (based on revisions
and meta-analyses) recommend performing US on admission or in the first 48 h.
Serum pancreatic enzyme measurement is the “gold standard” for the diagnosis of AP. In
an episode of AP, amylase, lipase, elastase, and trypsin are released into the bloodstream at
the same time but the clearance varies depending on the timing of blood sampling. Amylase
is an enzyme secreted by the pancreas, and also salivary glands, small intestine, ovaries,
adipose tissue, and skeletal muscles. There are two major isoforms of amylase: pancreatic
and salivary, and the leading function is digestion of starch, glycogen, and related poly- and
oligosaccharides, by hydrolysis. In AP, serum amylase levels usually rise within 6 to 24 h,
peak at 48 h, and decrease to normal or near normal levels over the next 3 to 7 days.
DISCUSSION
Lipase is another enzyme secreted by the pancreas. AP is the main reason for
an increase in lipase, and many investigators emphasize that lipase is more
specific, but can be found elevated also in non-pancreatic diseases such as renal
disease, appendicitis, acute cholecystitis, chronic pancreatitis, bowel obstruction,
etc. In AP, serum lipase remains elevated for a longer period than serum amylase.
It rises within 4 to 8 h, peaks at 24 h, and decreases to normal or near normal
levels over the next 8 to 14 days.
Trypsinogen is the zymogen of the pancreatic enzyme trypsin. In AP, the
serum and urinary concentrations of trypsinogen usually rise to high levels within
a few hours and decrease in 3 days.
CONCLUSIONS
These guidelines present evidence-based international consensus statements
on the management of severe acute pancreatitis from collaboration of a panel of
experts. It contains 55 statements on diagnosis, management in the ICU,
surgical and operative management, open abdomen, and antibiotic treatment.
For some of the statements such as severity grading, imaging, use of
prophylactic antibiotics and most aspect of the management in the ICU, the
evidence is strong. For others, such as laboratory diagnostics and surgical
strategies, for example, the evidence is quite weak requiring further studies.
With accumulating knowledge, the statements need to be regularly updated.
 ACUTE PANCREATITIS: CURRENT
PERSPECTIVES ON DIAGNOSIS AND
MANAGEMENT
By: Adarsh P Shah, Moustafa M Mourad, And Simon R
Bramhall
Published: March 9. 2018
10.2147/Jir.S135751
ABSTRACT
The last two decades have seen the emergence of significant evidence that
has altered certain aspects of the management of acute pancreatitis. While most
cases of acute pancreatitis are mild, the challenge remains in managing the severe
cases and the complications associated with acute pancreatitis. Gallstones are still
the most common cause with epidemiological trends indicating a rising
incidence. The surgical management of acute gallstone pancreatitis has evolved.
In this article, we revisit and review the methods in diagnosing acute pancreatitis.
We present the evidence for the supportive management of the condition, and
then discuss the management of acute gallstone pancreatitis. Based on the
evidence, our local institutional pathways, and clinical experience, we have
produced an outline to guide clinicians in the management of acute gallstone
pancreatitis.
 CONCLUSION
Acute pancreatitis is frequently encountered on the emergency surgical take. Once the
diagnosis is made, clinical efforts should simultaneously concentrate on investigating for the
underlying etiology and managing the condition by anticipating its complications, which can be
aided by using any of the severity scoring systems described. Management of acute pancreatitis is
largely supportive. There is still no consensus on the ideal type and regimen of fluid for
resuscitation, but goal-directed fluid therapy is associated with better outcomes. Early enteral
nutrition modulates the inflammatory response and improves outcomes by decreasing infective
complications of acute pancreatitis. Antibiotics should be used judiciously as prophylactic
antibiotics have not shown any benefit in preventing infective complications of acute pancreatitis.
Patients with mild acute gallstone pancreatitis should be recommended to undergo a laparoscopic
cholecystectomy at the index admission, while those with severe gallstone pancreatitis and evidence
of cholangitis and/or choledocholithiasis benefit from early ERCP. Patients with mild acute
gallstone pancreatitis and concurrent choledocholithiasis benefit from single-stage laparoscopic
cholecystectomy and bile duct exploration, subject to available local expertise. There is no
difference in mortality and morbidity between the single-stage and double-stage management of
choledocholithiasis. However, the single-stage approach reduces the length of hospital stay and