In the name of God

Acute Pancreatitis
 INTRODUCTION — 

• Acute pancreatitis is an acute inflammatory

process of the pancreas. It is usually
associated with severe acute upper
abdominal pain and elevated blood levels of
pancreatic enzymes
Acute Pancreatitis – Epidemiology

• 180,000 - >200,000 Hospital Admissions /

Year
• 20% have a severe course
– > 30% mortality for this group, which has not
significantly changed during the past few decades
despite improvement in critical care and other
interventions
 Etiology
• Gallstones (35%-60%)
– Gallstone pancreatitis risk is highest among
patients with small GS < 5mm and with
microlithiasis
– GS pancreatitis risk is also increased in women >
60 yrs
• Alcohol (30-40%)
– Not all alcoholics get pancreatitis (only about
15%)
Etiology – Drugs and Toxins (5%)

• Azathioprine
• Cimetidine
• Estrogens
• Enalapril
• Erythromycin
• Furosemide
• Scorpion Bites
• Blunt Trauma
• Iatrogenic – ERCP (1-7%)
• Infection
• Cystic Fibrosis
– 2-15% of patients

• Idiopathic (20-25%).
 Infection
• Ascaris
• CMV
• EBV
• Enterovirus
• HIV/AIDS
• Mycoplasma
• Varicella
 Clinical Presentation

• Clinical
– Continuous mid-epigastric / peri-umbilical
abdominal pain  Radiating to back, lower
abdomen or chest
• One characteristic of the pain that is present
in about one-half of patients, and that
suggests a pancreatic origin, is band-like
radiation to the back.
 Clinical Presentation

• More severe cases

– Jaundice
– Ascites
– Pleural effusions – generally left-sided
– Cullen’s sign – bluish peri-umbilical discoloration
– Grey Turner’s sign – bluish discoloration of the
flanks
• Grey Turner sign Cullen’s sign
 Physical examination

• fever, tachycardia, and, in severe cases,

shock and coma. tenderness and guarding
• Respirations may be shallow due to
diaphragmatic irritation from inflammatory
exudate, and dyspnea may occur if there is
an associated pleural effusion.
 Diagnosis – Amylase

• Elevates within HOURS and can remain

elevated for 4-5 days
• High specificity when using levels >3x normal
• Many false positives (see next slide)
Diagnosis – Amylase Elevation

– Biliary obstruction • Unknown Source

– Bowel obstruction – Renal failure
– Perforated ulcer – Head trauma
– Appendicitis – Burns
– Mesenteric ischemia
– Peritonitis
– Parotitis
– DKA
– Fallopian tube
– Malignancies
 Diagnosis – Lipase

• Begins to increase 4-8H after onset of

symptoms and peaks at 24H
• Remains elevated for days
• Sensitivity 86-100% and Specificity 60-99%
• >3X normal S&S ~100%
• phospholipase A, trypsin, carboxypeptidase
A, and co-lipase
 RADIOLOGIC FEATURES

• Important radiologic features may be seen on

a plain film of the abdomen, chest radiograph,
and spiral (helical) CT scan, Abdominal
ultrasound 
 Diagnosis – Imaging

• CT
– CT scan — CT scan is the most important imaging
test for the diagnosis of acute pancreatitis and its
intraabdominal complications and also for
assessment of severity.
– Search for necrosis – will be present at least 4
days after onset of symptoms
CT shows
significant
swelling
and
inflammation
of the
pancreas
 Diagnosis - Imaging

• ERCP (endoscopic retrograde

cholangiopancreatography)
– Diagnostic and Therapeutic
– Can see and treat:
• Ductal dilatation
• Strictures
• Masses / Biopsy
 Diagnosis – Imaging

• ERCP indications (should be done in the first 72hr)

– GS etiology with severe pancreatitis – needs sphincterotomy
– Cholangitis
– Dilated CBD
– If no GS found sphincterotomy is indicated anyway
– Pregnant patient
• Abdominal ultrasound — A diffusely
enlargement, hypoechoic pancreas is the
classic ultrasonographic image of acute
pancreatitis; it can also detect gallstones in
the gallbladder 
Prognosis – Ranson’s (Severe > 3)

• Ranson’s Score
– 5 on Admission
• Age > 55 y
• Glucose >200
• WBC > 16000
• LDH > 350
• AsT > 250
– 6 after 48 hours from presentation
• Hct > 10% decrease
• Calcium < 8
• Base Deficit > 4
• BUN > 5
• Fluid Sequestration >4L
• PaO2 < 60
• 5% mortality risk with <2 signs
• 15-20% mortality risk with 3-4 signs
• 40% mortality risk with 5-6 signs
• > 50% mortality risk with >7 signs
 Management

• The first step in managing patients with acute

pancreatitis is determining the severity. 
 Management

• SUPPORTIVE CARE — Mild acute pancreatitis

is treated with supportive care including pain
control, intravenous fluids, and correction of
electrolyte and metabolic abnormalities. The
majority of patients require no further therapy,
and recover and eat within three to seven days.
In severe acute pancreatitis, intensive care unit
monitoring and support of pulmonary, renal,
circulatory, and hepatobiliary function
 Management – Necrosis

• All severe pancreatitis should be managed in the

ICU

• Necrosis associated Infection generally requires

debridement (surgical)
 Management – Pain

• Meperidine has been favored over morphine for

analgesia in pancreatitis because studies
showed that morphine caused an increase in
sphincter of Oddi pressure.
• Hydromorphone
 Complications – Local

• Necrosis
– Sterile
– Infected - abscess
• Pseudocyst
• Ascites
• Intraperitoneal hemorrhage
• Thrombosis
• Bowel infarction
• Obstructive jaundice
 Complications – Systemic

• Pulmonary • Gastrointestinal
– Pleural effusions – PUD
– Atelectasis – Erosive gastritis
– Mediastinal abscess – Portal vein thrombosis
• Cardiovascular • Renal
– Hypotension – Oliguria
– Sudden death – Azotemia
– Pericardial effusion – Renal artery/vein throbosis
– DIC – ATN
 Complications – Long Term

• Chronic Pancreatitis
– Abdominal Pain
– Steatorrhea
– Exocrine insufficiency (pancreas has a 90%
reserve for the secretion of digestive enzymes)
– DM, i.e.Endocrine Insufficiency
‫ارائه دهنده ‪ :‬حسام الرفاعی‬