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Acute pancreatitis

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Kishor Thapa

Acute pancreatitis is a discrete episode of pancreatic injury and inflammation characterized by abdominal pain, nausea, vomiting, and elevated serum amylase and lipase levels. Gallstones and alcohol account for 70-80% of cases. Treatment involves early resuscitation, detecting and treating complications, establishing the diagnosis and severity, and treating the underlying cause. Complications can include systemic complications like shock, ARDS, and renal failure or local complications like pancreatic necrosis, pseudocyst formation, and gastrointestinal bleeding. The mortality rate is typically 2-20% depending on the severity of complications.

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Acute pancreatitis
Definition A discrete episode of pancreatic cellular injury & inflammation with: Abdominal pain, nausea, vomiting Elevated serum amylase & lipase Radiographic evidence of pancreatic inflammation, oedema or necrosis
Epidemiology Incidence 5 30 cases / 100000 population Increasing incidence due to increase in cholelithiasis associated with increasing prevalence of obesity
Aetiology Gallstones & alcohol account for 70 80% of all cases In 10% cause unknown
Common causes Gallstones Drugs & toxins Ethanol, methanol Tobacco Azathioprine, 6MPU, didanosine, pentamidine, Scorpion venom Organophosphate insecticides Trauma Post ERCP, blunt trauma, post-op Metabolic Hyperlipidaemia, hypercalcaemia Pancreatic duct obstruction Infections CMV, mumps, rubella Coxsackie B, ascaris Others Autoimmune, genetic 70 - 80% cases: gall stones & alcohol
Pathophysiology Trypsinogen Trypsin Activation of other digestive enzymes Pancreatic damage by necrosis, apoptosis, autophagy Damage to surrounding fat & structures, loss of fluid into retroperitoneal spaces Release of inflammatory cytokines & digestive enzymes into systemic circulation SIRS, hypotension, ARF, ARDS
Clinical Features Symptoms Pain abdomen Epigastric, radiating to back, reaches maximum intensity in 30 60 min, persists for days, steady Nausea Vomiting Signs Tachycardia Tachypnoea, dyspnoea, hypotension, altered sensorium
P/A Distended Tenderness in epigastric region guarding, rebound tenderness Diminished bowel sounds Grey-Turner & Cullen signs Others Icterus Dull percussion noted in lower lung fields
Laboratory Diagnosis Indicator tests Serum lipase Serum amylase Prognostic tests Leukocytosis (>15000/mm3) Haemoconcentration Raised BUN (>45mg/dL) CRP (>150 mg/L) Other Blood sugar (>180 mg/dL), corrected ser calcium (<8 mg/dL), ALT (> 200U/L), LDH (>600U/L), ser albumin (<3.2g/dL) Glasgow criteria for prognosis in acute pancreatitis
Imaging Utility Diagnosis Aetiology Prognosis Modalities USG CT for first attack, severe disease with systemic complications, failure to improve or when diagnosis not clear MRI + MRCP EUS ERCP
USG Pancreatic enlargement, oedema, associated periancreatic fluid collections Gall stones, dilated CBD CT More accurate than USG Contrast study helps estimate volume of necrotic & viable tissue Excludes other intra-abdominal mimics of pancreatitis Gall stones missed Assessment of severity & prognostication
Treatment General Supportive Care NPO Pain control narcotic analgesics IV Aggressive volume repletion Early enteral nutrition No role for prophylactic antibiotics Minimizing HAI by high quality nursing care, attention & care of lines & catheters Urgent ERCP & biliary sphincterotomy Interval cholecystectomy Establish diagnosis & severity Early resuscitation Detect & treat complications Treat underlying cause
Complications Systemic complications Hypotension & shock ARDS ARF DIC Hypocalcaemia Hyperglycaemia Hypertriglyceridaemia Encephalopathy/ coma
GI Bleeding Stress ulceration Pseudoaneurysm Local Pancreatic necrosis (sterile / infected) Acute fluid collection Pseudocyst Duodenal & biliary obstruction
Prognosis 80% recover quickly without serious complications Mortality due to MOSF secondary to pancreatitis or HAI Rate 2 20%

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Acute pancreatitis

  • 2. Definition A discrete episode of pancreatic cellular injury & inflammation with: Abdominal pain, nausea, vomiting Elevated serum amylase & lipase Radiographic evidence of pancreatic inflammation, oedema or necrosis
  • 3. Epidemiology Incidence 5 30 cases / 100000 population Increasing incidence due to increase in cholelithiasis associated with increasing prevalence of obesity
  • 4. Aetiology Gallstones & alcohol account for 70 80% of all cases In 10% cause unknown
  • 5. Common causes Gallstones Drugs & toxins Ethanol, methanol Tobacco Azathioprine, 6MPU, didanosine, pentamidine, Scorpion venom Organophosphate insecticides Trauma Post ERCP, blunt trauma, post-op Metabolic Hyperlipidaemia, hypercalcaemia Pancreatic duct obstruction Infections CMV, mumps, rubella Coxsackie B, ascaris Others Autoimmune, genetic 70 - 80% cases: gall stones & alcohol
  • 6. Pathophysiology Trypsinogen Trypsin Activation of other digestive enzymes Pancreatic damage by necrosis, apoptosis, autophagy Damage to surrounding fat & structures, loss of fluid into retroperitoneal spaces Release of inflammatory cytokines & digestive enzymes into systemic circulation SIRS, hypotension, ARF, ARDS
  • 7. Clinical Features Symptoms Pain abdomen Epigastric, radiating to back, reaches maximum intensity in 30 60 min, persists for days, steady Nausea Vomiting Signs Tachycardia Tachypnoea, dyspnoea, hypotension, altered sensorium
  • 8. P/A Distended Tenderness in epigastric region guarding, rebound tenderness Diminished bowel sounds Grey-Turner & Cullen signs Others Icterus Dull percussion noted in lower lung fields
  • 9. Laboratory Diagnosis Indicator tests Serum lipase Serum amylase Prognostic tests Leukocytosis (>15000/mm3) Haemoconcentration Raised BUN (>45mg/dL) CRP (>150 mg/L) Other Blood sugar (>180 mg/dL), corrected ser calcium (<8 mg/dL), ALT (> 200U/L), LDH (>600U/L), ser albumin (<3.2g/dL) Glasgow criteria for prognosis in acute pancreatitis
  • 10. Imaging Utility Diagnosis Aetiology Prognosis Modalities USG CT for first attack, severe disease with systemic complications, failure to improve or when diagnosis not clear MRI + MRCP EUS ERCP
  • 11. USG Pancreatic enlargement, oedema, associated periancreatic fluid collections Gall stones, dilated CBD CT More accurate than USG Contrast study helps estimate volume of necrotic & viable tissue Excludes other intra-abdominal mimics of pancreatitis Gall stones missed Assessment of severity & prognostication
  • 12. Treatment General Supportive Care NPO Pain control narcotic analgesics IV Aggressive volume repletion Early enteral nutrition No role for prophylactic antibiotics Minimizing HAI by high quality nursing care, attention & care of lines & catheters Urgent ERCP & biliary sphincterotomy Interval cholecystectomy Establish diagnosis & severity Early resuscitation Detect & treat complications Treat underlying cause
  • 13. Complications Systemic complications Hypotension & shock ARDS ARF DIC Hypocalcaemia Hyperglycaemia Hypertriglyceridaemia Encephalopathy/ coma
  • 14. GI Bleeding Stress ulceration Pseudoaneurysm Local Pancreatic necrosis (sterile / infected) Acute fluid collection Pseudocyst Duodenal & biliary obstruction
  • 15. Prognosis 80% recover quickly without serious complications Mortality due to MOSF secondary to pancreatitis or HAI Rate 2 20%