"Love is like pancreatitis; it starts off slow, then builds in intensity until you become consumed and develop violent cramps." Dana Gould

1. Dr Fawwaz BinShahab
Post Graduate trainee,
surgical Unit 4
Acute Pancreatitis

2. OVERVIEW
• Acute pancreatitis refers to an acute inflammatory process of the
pancreas, usually accompanied by abdominal pain and elevations of
serum pancreatic enzymes.
• This syndrome is usually a discrete episode, which may cause varying
degrees of injury to the pancreas, and adjacent and distant organs.

4. TYPES OF ACUTE PANCREATITIS
• ACUTE INTERSTITIAL / EDEMATOUS
PANCREATITIS
• 80 %
• The gland architecture is preserved
but is edematous. Inflammatory
cells and interstitial edema are
prominent within the parenchyma.
• Usually self limited with transient
clinical manifestation.
• ACUTE NECROTIZING /
HEMORRHAGIC PANCREATITIS
• 20%
• Marked necrosis, hemorrhage of
the tissue, and fat necrosis, along
with vascular inflammation and
thrombosis.
• Much higher morbidity and
substantial mortality rates.

5. PATHOGENESIS

6. ETIOLOGY

7. SIGNS AND SYMPTOMS

9. CRITERIAS TO DETERMINE THE SEVERITY AND
ASSOCIATED MORTALITY OF PANCREATITIS

10. GLASGOW SCALE

12. INVESTIGATIONS FOR ACUTE PANCREATITIS
• Bedside
• Vitals ( Pulse , BP, Saturation monitoring)
• ECG (if tachycardiac or deranged electrolytes)
• Beta-HCG
• Blood Tests
• Amylase/lipase (Serum amylase or Lipase > 3 times above normal limit is diagnostic )
• FBC
• UCE
• CRP
• LFT (including AST)
• LDH
• Serum glucose
• Lipids
• Arterial blood gas (used for scoring acute pancreatitis)

13. Imaging investigations:
• Ultrasound: used to demonstrate gallstones or a dilated common bile
duct. The pancreas may be visualized.
• Computed tomography: used to confirm diagnosis when uncertainty
remains and to exclude complications of disease.

14. Initial Management of Acute Pancreatitis
SUPPORTIVE CARE
• VOLUME RESUSCITATION:
Aggressive Fluid resuscitation to compensate for third-space losses,
particularly in the first 24 hours, targeting urine output >o.5 ml/kg/hr
• ADEQUATE ANELGESIA
• RESPIRATORY MONITORING AND ABGS:
To access oxygenation and acid base status, since hypoxemia is common
secondary to the aggressive fluid resuscitation and potential for
development of sympathetic effusions.

15. Initial Management of Acute Pancreatitis
• GASTRIC REST WITH NUTRITIONAL SUPPORT
In mild cases, a low fat diet may be reintroduced once tolerated by the patient (i.e. the
pain has settled and they have an appetite).
Enteral feeding is preferred to total parenteral nutrition as it helps maintain the mucosa
and prevent translocation of bacteria. Nasojejunal feeding is commonly used.
Total parenteral nutrition should be used in patients with ileus or where nutritional
requirements are not being met.
• ANTIBIOTICS:
Antibiotics are not routinely indicated in acute pancreatitis and they should not be used
prophylactically.
Infection remains a significant cause of mortality in pancreatitis. Antibiotics should be
commenced in patients with suspected infected pancreatic necrosis

16. INTERVENTIONAL AND SURGICAL TREATMENT:
For developing pancreatic collection and necrosis
• SURGICAL OPTIONS FOR GALL STONE PANCREATITIS:
• Early lap cholecystectomy within same admission with operative
cholangiogram, in mild acute pancreatitis.
• In patients with severe attack, early ERCP followed by delayed lap
cholecystectomy.
• In patients with severe pancreatitis there is an 82.6% morbidity and 47.8%
mortality from cholecystectomy if performed within the initial 48 hours. If
deferred until the signs of pancreatitis have subsided, morbidity and
mortality fall to 17.8% and 11.8% respectively.

17. INDICATIONS OF ERCP IN PATIENTS WITH ACUTE
PANCREATITIS
Preferred within 72 hours in patients with acute biliary pancreatitis or
with signs of cholangitis

18. ALGORITHM OF MANAGEMENT OF BILIARY
PANCREATITIS

20. INDICATIONS OF CT SCAN IN PANCREATITIS

21. CT SEVERITY INDEX / BALTHAZAR CRITERIA
BASED ON IMAGING CHARACTERISTICS

22. Prognosis based on CTSI

23. COMPLICATIONS OF ACUTE PANCREATITIS
LOCAL COMPLICATIONS
(usually develop after the 1st week)
• Acute fluid collections
• Sterile pancreatic necrosis
• Infected pancreatic necrosis
• Pancreatic abscesses
• Pseudocyst
• Pancreatic ascites
• Pleural effusion
• Portal/ splenic vein thrombosis
• Pseuodoaneurysm
SYSTEMIC COMPLICATIONS
(common in 1st week)
• CVS: shock, arrhythmias
• Pulmonary: ARDS
• Renal failure
• DIC
• Metabolic: Hypo Ca, Hyper-lipidemia,
Hyperglycemia
• GI: Ileus
• Neurological: Confusion, irritability ,
encephalopathy.

24. APFC (ACUTE PERIPANCREATIC FLUID
COLLECTION)
• Occurs early in the course of
pancreatitis
• No encapsulating wall.
• No intervention is required unless
its a large collection with
pressure effects , where
percutaneous aspiration under us
or CT guidance , or transgastric
drainage under EUS guidance is
an option. • 45-year-old man with abdominal pain for 3 days due to
acute pancreatitis. Axial contrast-enhanced CT scan
shows diffuse parenchymal swelling of pancreas
(arrowhead) and peripancreatic fat infiltration and small
amount fluid collection without enhancing wall without
necrosis

26. PANCREATIC NECROSIS
• Diffuse or focal area of non viable
parenchyma. Initially sterile , but later
often becomes infected
• This is associated with lysis of
peripancreatic fat and is called ACUTE
NECROTIC COLLECTION.
• Over 4 weeks, this becomes well defined
inflammatory capsule and evolve into
walled off necrosis (WON)
57-year-old man with abdominal pain for 2
days. Axial contrast-enhanced
CT scan shows peripancreatic fluid collection
(arrows) extending to Lt. anterior para renal
space and swelling of pancreas (only visible
body portion) with focal non-enhancing
portion in tail of pancreas (arrowhead),
indicative of necrosis.

27. • 34-year and 57-year-old men with
chronic abdominal pain.
• a) multifocal necrotic fluid
collection with peripheral
enhancement (arrows) in
peripancreatic, omentum and small
bowel mesentery, indicative of
maturating fluid collection.
• b) peripheral enhancing fluid
collection with internal entrapped air
bubbles (arrowhead) around tail of
pancreas, indicative of infection.

28. Treatment options for pancreatic necrosis
• Conservative management.
• Percutaneous Aspiration of infected pancreatic necrosis under US or CT guidance
• Often repeated drainage and repeated insertion of wider drains
• Pancreatic necrosectomy (thorough debridement of dead tissue around the
pancreas)
• If further necrotic tissue forms after a necrosectomy (MANAGEMENT OF POST
NECROSECTOMY NECROTIC TISSUE), following options are present
o Closed continuous lavage (Of Berger)
o Closed drainage
o Open packing
o Closure and relaparotomy

29. `

30. PANCREATIC PSEUDOCYSTS:
39-year and 43-year-old men with acute
pancreatitis and pseudocysts formation.
• a) Axial contrast-enhanced CT scan
shows ovoid shape peripheral rim
enhancing lesion (arrowhead),
indicative of pseudocyst, in lesser sac
and detectable peripancreatic fluid
collection and fat infiltration (arrows).
• b) Axial contrast-enhanced (b) CT
scan shows two pseudocysts
(arrowhead) in head of pancreas and
pancreaticoduodenal groove,
respectively

31. TYPES OF PSEUDOCYST

32. MANAGEMENT OF PSEUDOCYST

33. Important facts regarding management of
pseudocyst
• A pseudocyst should be differentiated from cystic mucinous
neoplasms of pancreas by evaluating the cystic fluid aspirate for CEA ,
AMYLASE and Cytology.
• Percutaneous drainage should be mostly avoided , particularly if it’s a
communicating pseudocyst (because of the development of
pancreatico-cutaneous fistula), or unless one is absolutely certain that
it is not neoplastic.
• Communicating pseudocysts can be treated by ERCP and placement
of pancreatic stent across the ampulla to provide adequate drainage.
• Non Communicating pseudocysts mostly require Surgical or
endoscopic drainage into the adjacent hollow viscus.

35. ANC AND SPLENIC VEIN THROMBOSIS
• 46-year-old man with abdominal
pain due to necrotizing
pancreatitis. Axial contrast-
enhanced CT scan shows
parenchymal necrosis in
pancreas (*) and non-enhancing
subtle heterogeneous
peripancreatic fluid collection,
indicative of acute necrotic
collection (arrowheads). Splenic
vein thrombosis (arrow) is also
detectable.

36. ANY QUESTIONS BEFORE THE QUIZ

39. The following physical examination findings may be noted, varying with the severity of the
disease:
•Fever (76%) and tachycardia (65%) are common abnormal vital signs; hypotension may
be noted
•Abdominal tenderness, muscular guarding (68%), and distention (65%) are observed in
most patients; bowel sounds are often diminished or absent because of gastric and
transverse colonic ileus; guarding tends to be more pronounced in the upper abdomen
•A minority of patients exhibit jaundice (28%)
•Some patients experience dyspnea (10%), which may be caused by irritation of the
diaphragm (resulting from inflammation), pleural effusion, or a more serious condition,
such as acute respiratory distress syndrome (ARDS)
•In severe cases, hemodynamic instability is evident (10%) and hematemesis or melena
sometimes develops (5%); in addition, patients with severe acute pancreatitis are often
pale, diaphoretic, and listless
•Occasionally, in the extremities, muscular spasm may be noted secondary to

40. A 60 year old man presented to the OPD with symptoms suggestive of acute pancreatitis. He
consumes high quantities of alcohol regularly. His symptoms started 4 days ago. But he continued
to consume alcohol. He was admitted for further evaluation. Presently, he has severe vomiting. He
also complains of dizziness when standing. Examination revealed tenderness in the epigastrium
and right hypochondrium. A reddish discoloration is noted in the flanks. Which of the following
statements regarding the patient is most accurate?
A. The patient should be evaluated for concomitant appendicitis
B. USG is likely to demonstrate pseudocyst of pancreas
C. Contrast CT scan of the abdomen will reveal severe necrotising pancreatitis
D. Pancreatic calcification will be seen in X-ray abdomen

41. • Correct answer : C. Contrast CT scan of the abdomen will reveal severe
necrotising pancreatitis.