By: Amina A. Al-Qaysi
• Aetiology & Pathogenesis
• Signs & Symptoms
• Inflammation of the pancreatic parenchyma.
1. Acute: Emergency condition.
2. Chronic: Prolonged & frequently lifelong
disorder resulting from the development of
fibrosis within the pancreas.
Acute condition of diffuse pancreatic
inflammation & autodigestion, presents with
abdominal pain, and is usually associated with
raised pancreatic enzyme levels in the blood &
• Reversible inflammation of
• Ranges from mild to severe.
• Acute pancreatitis accounts for 3% of all cases
of abdominal pain among patients admitted
to hospital in the UK.
• Affect 2 – 28 per 100 000 of population.
• It may occur at any age, peak incidence is
between 50 and 60 years.
• Women are affected more the men, but men
are more likely to suffer recurrent attacks.
• 80% of the cases are due to gallstones & alcohol.
• The remaining 20 % of cases are due to:
1. Congenital: Pancreatic divisum
2. Metabolic: Hyperlipidemia, Hypercalcemia.
3. Toxic: Scorpion venom
4. Infective: Mumps, Coxsackie B, EBV, CMV.
5. Drugs: Azathioprine,
6. Vascular: Ischemia, Vasculitis
7. Autoimmune: Hereditary
9. Miscellaneous: CF,
• Mnemonic for the causes of Acute Pancreatitis:
‘I get smashed‘
Scorpion / Snakes
Hyperlipidaemia / Hypercalcaemia
• Biliary Pancreatitis:
1. Common channel
sphincter of Oddi
3. Obstruction of the
- Direct toxic effect on the pancreatic acinar
- Stimulation of the pancreatic secretion
- Constriction of the sphincter of Oddi
• Upper Abdominal pain,
sudden onset, sharp, severe,
continuous, radiates to the
back, reduced by leaning
Generalized abdominal pain,
radiates to the shoulder tips.
Patient lies very still.
• Nausea, non-projactile
• Fever, weakness
• Distressed, moving continuously, or sitting still
• Pale, diaphoretic. Confusion
• Low grade fever
• Tachycardia, Tachypnea
• Shallow breathing
• Mild icterus
• Abdominal distension (Ileus, Ascites)
• Grey Turner’s sign, Cullen’s sign, Fox’s sign
• Rebound tenderness, Rigidity
• Shifting dullness, reduced bowel sounds
Cullen’s Sign Grey Turner’s Sign
• Subcutaneous nodular fat necrosis
• Tender red nodules
• Usually measures 0.5 – 2 cm
• Usually over the extremities
Perforated viscus (DU)
Acute cholecystits, Biliary colic
Acute intestinal obstruction
Mesenteric vascular obstruction
Dissecting aortic aneurysm
Should be aimed at answering three
1. Is a diagnosis of acute pancreatitis correct ?
2. How severe is the attack ?
3. What is the aetiology ?
• Complete Blood Count
• Serum amylase & lipase
• C-reactive Protein
• Serum electrolytes
• Blood glucose
• Renal Function Tests
• Liver Function Tests
• Coagulation profile
• Arterial Blood Gas Analysis
• Sensitivity: 72% Specificity: 99%
• Released within 6-12 hours of the
onset, & Remains elevated for 3-5
• Elevation ˃ 3X normal is significant.
• Undergoes renal clearance. After its
serum levels decline, its urinary
level remains elevated.
• Its level doesn't correlate with the
• More pancreatic-specific than s. Amylase.
• Sensitivity: about 100% Specificity: 96%
• Remains elevated longer than amylase (up to
• Useful in patients presenting late to the
• S. Amylase tends to be higher in gallstone
• S. Lipase tend to be higher in alcoholic
• Plain erect chest X-ray: not diagnostic on
pancreatitis, but to rule out other D/D
• Pleural effusion, diffuse alveolar infiltrate (ARDS)
Sentinel Loop Sign
Colon cut-off sign
• CT Scan: not indicated in every patient, only
1. Diagnostic uncertainty.
2. Severe acute pancreatitis.
3. Clinical deterioration, with multi-organ failure,
sepsis, progressive deterioration.
4. Local complications occurs (fluid collection,
Axial CT Scan: Peripancreatic stranding
(arrow). Multiple gallstones in the
Contrast-enhanced CT: acute necrotising
pancreatitis. Pancreatic area of reduced
enhancement, peripancreatic edema and
stranding of the fatty tissue
Pancreatic pseudocyst occupying the
head of the pancreas. The pancreatic
duct (arrow) is dilated
CT Severity Index = Balthazar
Grade + Necrosis Score
• Endoscopic Ultrasound, MRCP: CBD
stones detection, assessment of pancreatic
parenchyma. Not widely available.
• ERCP: CBD stones identification & removal.
Urgent ERCP in severe acute gallstone
pancreatitis & signs of ongoing biliary
obstruction & cholangitis.
ERCP in Acute Pancreatitis
Goals of Treatment
• Aggressive supportive care
• Decrease inflammation
• Limit superinfection
• Identify and treat complications
(of pancreatitis & its treatment)
• Treat cause if possible
• Gain IV access, obtain blood sample, rapid fluid
resuscitation & electrolytes replacement.
• Give analgesics (IM pethidine).
• Give Anti-emetics.
• Keep the patient NPO (until pain free/2-3 days).
• NGT insertion to relieve vomiting.
• Urinary catheterization is done.
• Monitor the vital signs.
• Injection Ranitidine 50 mg IV 8 hourly, or
Omeprazole 40 mg IV BD.
• Somatostatin or octreotide (pancreatic
• Respiratory support: oxygen supplementation,
or Venti mask
• ICU admission if severe acute pancreatitis.
Role of Antibiotics
• Prophylactic antibiotics have shown No decrease in
mortality in severe acute pancreatitis.
• Antibiotics are justified if:
1. Gas in retroperitoneal space
2. Needle aspiration of necrotic material confirms
4. CRP of ˃ 120 mg/L
5. Peri-pancreatic fluid collection
6. Organ dysfunction
7. APACHE II Score of ˃ 6
• Surgery has no immediate role in acute
• Aggressive surgical pancreatic debridement
(Necrosectomy) should be undertaken soon
after confirmation of the presence of infected
• Pseudocyst: Cystogastrostomy,
• Cardiovascular: Shock, Arrhythmias, Pericardial
• Pulmonary: Basal atelactasis, pleural effusion, ARDS
• Renal: ATN, Renal failure
• Haematological: DIC
• Metabolic: Hypocalcemia, Hyperglycemia,
• GIT: Ileus
• Neurological: Confusion, Irritability, Encephalopathy
• Miscellaneous: Subcutaneous fat necrosis, Arthralgia
Acute fluid collection:
• Occurs early in the course of acute pancreatitis
• Located in or near the pancreas, the wall encompassing
the collection is ill defined, the fluid is sterile.
• Most of such collections resolve, & no intervention is
necessary unless a large collection causes symptoms or
pressure effects, in which case it can be percutaneously
aspirated under ultrasound or CT guidance.
• Transgastric drainage under EUS guidance is another
• An acute fluid collection that does not resolve can
evolve into a pseudocyst or an abscess if it becomes
• Wall formed by granulation
tissue & fibrosis
• typically presents as
abdominal pain, abdominal
mass, & persistent
hyperamylasemia in a patient
with prior pancreatitis.
Transgastric Endoscopic Pseudocyst
Sterile and infected pancreatic necrosis:
• Diffuse or focal area of non-viable parenchyma,
typically associated with peripancreatic fat
necrosis. These areas can be identified by an
absence of contrast enhancement on CT.
• They’re sterile to begin with, but can become
subsequently infected, due to the gut bacterial
• Sterile necrotic material should not be drained
or interfered with.
• If the patient shows signs of sepsis, then one
should determine whether the necrosis is
• Mild acute pancreatitis: Mortality rate of 1%
• Severe pancreatitis: Mortality rate of 75-90%
• Overall mortality rate of 15-20%
• First week of illness -> MODS
• Subsequent weeks -> infection
• Bailey’s & Love’s Short Practice of Surgery, 25th
Edition, Page 1138 – 1146.
• Essential Surgery, Burkitt, 4th Edition, Page 380 –
• Robbins & Cotran Pathologic Basis of Disease, 8th
Disorder of the exocrine pancreas
Predominantly d/t activation of intracelluler trypsinogen to trypsin
peak in young men and older women.
Gallstones: females Alcohol: males
Widespread fat necrosis of the omentum. A test tube has been filled with blood-stained peritoneal fluid. This specimen was rich in amylase. Fat necroses are dull, opaque, yellow-white areas suggestive of drops of wax. They are most abundant in the vicinity of the pancreas, but are widespread in the greater omentum and the mesentery.
At necropsy, they can sometimes be demonstrated beneath the pleura and pericardium, and even in the subsynovial fat of the knee joint. Fat necroses consist of small islands of saponification caused by the liberation of lipase, which splits into glycerol and fatty acids. Free fatty acids combine with calcium to form soaps (fatty necrosis)
Acute pancreatitis. The microscopic field shows a region of fat necrosis on the right and focal pancreatic parenchymal necrosis (center).
Jaundice: obstruction of CBD d/t pancreatic head edema or cholidocholithiasis
d/t fat necrosis & retroperitoneal bleeding
Severe necrotizing pancreatitis
Fox’s sign: bruising over the inguinal ligament
Esophageal rupture: HX of emesis
Leukocytosis, hemoconcentration (elevated hgb & hct)
Hyperglycemia: reduced insulin release, increase glucagon release, increase adrenal corticosteroids & catecholamines
ECG: abnormalities simulating MI
Dx: 1. typical abdominal pain, with 2. increased amylase or lipase (3X normal), or 3. imaging finding compatible with pancreatitis
Half life in the blood is about 10 hrs
Renal failure: reduced renal clearance
Normal serum amylase level doesn't rule out Acute pancreatitis, and the level poorly correlates with the severity.
Prolonged amylase elevation (>1 week) may be a clue to the presence of pancreatic abscess, pseudocyst, or ascites.
Slightly greater sensitivity, specially when measured after 24 hrs of the presentation
d/d esophageal rupture
Doesn’t establish the Dx.
Edematous pancreas, extra-pancreatic fluid collection, gallstones, dilated CBD.
To be done in the first 24 hrs.
Limited value d/t presence of intestinal gas.
CT is the most important imaging investigation in A.P. It assess severity, complications
Areas of necrosis: non enhancing regions more than 3 cm, on IV contrast if renal function permits
CT or US guided aspiration to differentiate sterile from infected pancreatic necrosis or pseudocyst
CRP ˃110 mg/L
Ranson’s score ˃ 3, APACHE II score ˃8
Early intervention (˂72 hrs) is favoured in severe biliary pancreatitis
In acute biliary pancreatitis but without obstructive jaundice, early ERCP & papillotomy are not beneficial
If 3 or more factors are present in the patient, it indicates severe pancreatitis.
Gain IV access, rapid fluid resuscitation & electrolytes replacement (key factor in the tt of acute pancreatitis).
Hourly urine output
Somatostatin or octreotide: reduce mortality rate but no change in the complications
Cefuroxime : 2nd generation cephalosporin
Enteral nutrition is preferred to parental nutrition for improving patient outcomes
Purtscher retinopathy (funduscopy ) ischemic injury to the retina causing temporary/permanent blindness
CT of pancreatic pseudocyst. A large pseudocyst is seen in the head of the pancreas. A nasojejunal feeding tube is seen anterolaterally.
MC cause of early death in A. P. Patients is hypovolemic shock