This study analyzed 107 cases of acute pancreatitis treated at a hospital in Islamabad, Pakistan over one year. Gallstones were found to be the most common cause, accounting for 36.5% of cases. Alcohol was a factor in 11.2% of cases. In 46.7% of cases, no clear cause was identified. Based on the Ranson score, 35.5% of cases were considered severe. The average hospital stay was 8.9 days and mortality rate was 8.4%, with all deaths occurring in severe cases. The authors conclude that while the causes and severity of acute pancreatitis in Pakistan are generally similar to other countries, gallstones are a relatively more common cause than alcohol compared to Western

1. Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad, Pakistan. Zakaur Rab Siddiqui et al
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 1
Original Article
Presentation and Outcome of
Acute Pancreatitis at Pakistan
Institute of Medical Sciences,
Islamabad, Pakistan.
Study Conducted at: Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
Category: Original article surgeon-in-trainingaudit article.
Short Title: Pattern of Acute Pancreatitis in Islamabad, Pakistan.
Presentation and Outcome of Acute Pancreatitis at Pakistan Institute of Medical Sciences,
Islamabad.
Background: Acute pancreatitis is an important cause of abdominal pain that may be
associated with significant morbidity for the patient and considerable workload for the
hospital. Our impression has been that it is becoming increasingly common, perhaps in
tandem with westernized lifestyle or other unknown cause.
Objectives: To enlist the various presentations, assess the severity of the disease by
employing Ranson’s criteria and pattern of outcome in terms of duration of hospital stay,
morbidity and mortality in our set up.
Design: A single institution based descriptive study.
Setting: Department of surgery, Pakistan Institute of Medical Sciences, Islamabad.
Duration of Study: For a period of one year from 1st January, 2006 to 31st December,
2006.
Patients and Method: All patients presenting with signs and symptoms of
acute pancreatitis and raised amylase level (greater than 5 times normal) in the
period of study were included in the study. The data of 107 consecutive patients
admitted with the diagnosis of acute pancreatitis was collected through a proforma
and assessed with reference to clinical presentation, etiological factors, severity (using
Ranson ‘s score), length of hospital stay, surgical intervention if required and outcome
in each case.
Results: Out of 107 patients, there was male predominance with a male: female of 1.1:1.
The mean age was 43.96+17.45 years with a range of 11 -88 years. Eighty -six (80%) patients
presented in emergency with pain, nausea and vomiting as the main symptoms .In 50
cases(46.7%), the etiology remained unknown, while in the remaining cases the most
common aetiological factor for acute pancreatitis was gallstones i.e., in 39 cases(36.45%)
followed by alcohol in 12 cases (11.2%). The severity of the disease based on Ranson score
was <3 in 50(46.7%), 3 in 19(17.8%) and >3 in 38(35.5%) patients. The average length of stay
was 8.91+7.3 days and the mortality was 8.4% but the morbidity remained high with the
sequelae of resolution in >50% cases.
Conclusion: Acute pancreatitis shows a comparable frequency in our set up when
compared to the world literature. However, when compared with etiology and presentation,
the gallstones rather than alcohol constitute the main cause in our setup. Meanwhile, due to
adoptation of Western way of life, the incidence seems to be increasing.
Key Words: Acute Pancreatitis, gallstones, Ranson score.
Zakaur Rab Siddiqui*
Aatif Inam**
Muhammed Saaiq***

2. Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad, Pakistan. Zakaur Rab Siddiqui et al
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 2
Introduction
Acute Pancreatitis is a common disorder
with potentially devastating consequences. It is a
multifaceted disease with multiple etiologies and there is
a wide variability in the presentation and clinical course
of the disease1-3. The incidence of acute pancreatitis is
known to differ geographically due to differences in
alcohol consumption or in incidence of gallstones
disease in different parts of the world4, 5. Nearly 25% of
all attacks of pancreatitis have severe complications and
the death rate of clearly diagnosed cases has remained
high at 10-25% over the past few years7. Most studies
on acute pancreatitis are based on the Western
population8. It is generally perceived that acute
pancreatitis runs a benign course in Asian countries and
the etiology is different from that of the Western
population.
There is very little information in literature
describing etiology and clinical outcome of acute
pancreatitis in our population. This review describes the
demographic, etiological and clinical course of acute
pancreatitis in our setup.
Patients and Methods
The study was conducted at Department of
surgery, Pakistan Institute of Medical Sciences,
Islamabad. It was a prospective study of 107
consecutive admissions for acute pancreatitis for the
period January 2006 to December 2006. The diagnosis
of acute pancreatitis was accepted when a compatible
clinical picture was associated with raised serum
amylase of more than five times the normal value.
Evidence from laparotomy was also accepted for the
diagnosis. Ultrasonography was routinely performed for
all patients diagnosed to have acute pancreatitis and
contrast dynamic computerized tomography (CT) scan
was performed on patients judged to have severe
disease.
Alcohol was considered the etiology when
patient volunteered a history of a recent binge of alcohol
or reported a regular intake. Gallstone related disease
was based on identification of gallstones by ultrasound,
endoscopic retrograde cholangiopancreatograpy
(ERCP) or CT scan. Traumatic pancreatitis was
diagnosed if the disease occurred after an episode of
trauma. The etiology was considered to be unknown
when no identifiable factor could be found. The severity
of acute pancreatitis was stratified using the Ranson
score. The disease was considered severe when the
Ranson score was greater than 3. Aggressive treatment
in an intensive care or a high dependency unit was
instituted if a diagnosis of severe acute pancreatitis
was made. All complications were managed with
appropriate surgical approaches. The data was
analyzed through SPSS version 13 and descriptive
statistics was used to calculate frequencies, ratios,
percentages, means and standard deviation. Graphs
and tables were used for data presentation.
Results
The 107 consecutive admissions occurred for
acute pancreatitis during the period of study. Fourteen
patients had recurrent admissions for recurrent
attacks of pancreatitis, of which 9 were secondary
to the biliary cause. The mean age of the patients was
44 years (SD ± 17 years) with the range of 11 to 88
years and they consisted of 56 males and 51 females
(M: F = 1.1:1).The sex difference seen among the
patient was not statistically significant (p>0.05). Eighty -
six (80%) patients presented in emergency with pain,
nausea and vomiting as the main symptoms. Gallstones
were identified as the predominant factor associated
with acute pancreatitis in this study and it was noted
Table No. I: Ranson Score of the Patients
Score
Frequency
(n=107)
Percentage
(%)
0 - 2 50 46.7
3 19 17.8
4 - 5 28 26.2
> 5 10 9.5
Table No. II: Duration of Hospital Stay in
Patients with Acute Pancreatitis
Duration
No. of Patients
(n=107)
Percentage
(%)
0 Days
Upto 1 week
1-2 weeks
> 2 weeks
03
54
35
15
2.8
50.6
32.7
14.0

3. Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad, Pakistan. Zakaur Rab Siddiqui et al
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 3
in 39 patients (36.45%) of which 4 of the patients
had dilated common bile duct with stones. Twelve
patients (11.2%) were diagnosed to have pancreatitis
secondary to alcohol and other factors identified in
6 patients included trauma in four patients (3.74%),
hyperlipidaemia in one patient (0.9 %) and carcinoma
pancreas in one patient (0.9%). In 50 patients (46.7%),
no known factors would be identified. Gallstone
pancreatitis was predominantly a disease of the
female, that is, 27 out of 51(53.0%); while in both
alcohol (21.4%) and gallstones (21.4%) comprises
the main causes (n = 12 each). Using the Ranson
classification, 69 (64.5%) of the acute pancreatitis were
classified as mild disease, while 38(35.5%) as severe
disease (Table I). Twenty-seven patients manifested
local complications in the form of peri pancreatic
collection pseudocyst, necrosis and abscess (Table III).
There were 9 deaths, giving a mortality rate of 8.4%
and all occurred in patients with severe disease. The
average length of stay was 8.91 + 7.3 days (Table II)
and the mortality rate was 9 (8.4%). All of them
amongst severe pancreatitis patients. All the patients
having pancreatitis secondary to gallstones undergone
cholecystectomy either during same admission or after
some interval.
Table No. III: Complications Associated
with Severe Disease
(n=27)
Peripancreatic fluid collection 20
Pancreatic pseudocyst 04
Pancreatic abscess 01
Pancreatic necrosis 02
Table No. IV: Etiology and Severity of
Disease
Etiology Severity of Disease
Mild
(n=69)
Severe
(n=38)
Gallstones 23(33.3%) 16(42.1%)
Alcohol 8(11.6%) 4(10.5%)
Unknown 5(7.3%) 1(2.6%)
Others 33(47.8%) 17(44.7%)
PATTERN OF DISEASE AMONG
DIFFERENT AGE GROUP
9
19 20 19 19
11 10
0
5
10
15
20
25
11-
20
21-
30
31-40 41-50 51-60 61-70 >70
AGE (in years)
NO.OFPATIENTS
Figure I: Showing Pattern of Acute
Pancreatitis among Different Age Groups
Discussion
Although, there are various factors capable of
precipitating acute pancreatitis, biliary lithiasis and
alcohol together account for about 80% of the
disease.1, 2. Gallstones were recognized to be the
predominant factor responsible for acute pancreatitis,
representing 40 to 60 per cent of cases4, 5, 11, 12.
However, more recent reports suggest alcohol as the
most common etiological factor6, especially in the west.
Alcohol as an etiology was uncommon in Pakistan as
religion prohibits Muslims from consuming alcohol.
In our study gallstones were identified as the
most important etiologic factor associated with acute
pancreatitis, accounting for 36.5% of the cases. Alcohol
related pancreatitis was observed in 11.2% of the cases.
A similar observation was made by Zahra F et al10
and Asifi M et al11 in a study performed at Sri Ganga
Ram Hospital and Mayo Hospital in Lahore, Pakistan in
which they found cholelithiais as a predominant cause.
In 47% of the cases reviewed, no known factors could
be identified. It is possible that small gallstones and
biliary sludge were missed in the routine ultrasound
examination of the biliary system. The sensitivity of
routine ultrasonography in the detection of gallstones is
reported to in the range of 87 to 98%20.
Several studies have shown that biliary sludge
can be detected in many patients labeled as “idiopathic”
pancreatitis21, 22. It is important to be thorough with
investigations in this group of patients and repeat
examination may increase the proportion with an
identified etiology.

4. Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad, Pakistan. Zakaur Rab Siddiqui et al
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 4
GENDER DISTRIBUTION OF ACUTE
PANCREATITIS
48%52%
M F
Figure II: Showing Gender Distribution of
Acute Pancreatitis (M=Male; F=Female)
The extent of incidence where the known
etiological factors are not identified will vary according to
the thoroughness of the assessment. The report by
Mahendra RS et al8 and Kandasami P et al9, similarly
could not establish the etiology in most of the
cases. Mahendra RS et al8 noted abnormal serum
transaminase levels in 35% of the cases and concluded
the possibility of biliary microliths as a possible cause.
However, the etiology was recorded at discharge from
hospital, and very few patients had further outpatient
investigations which could have elucidated a cause in
some cases.
It may be postulated that microliths and
biliary sludge may be a problem peculiar to our
population in Pakistan. The most effective plan of
treatment for acute pancreatitis is aimed at identifying
the mechanism responsible for its development. The
investigation into the etiology of acute pancreatitis in our
community will have to include more sensitive tools
like Endoscopic retrograde cholangiopancreatography
(ERCP), endoscopic ultrasonography or magnetic
resonance cholangiography.
Acute pancreatitis is a protean disease,
capable of wide clinical variation ranging from a
mild, self limiting disease to a severe disease with
devastating consequences2. Most of the studies on
acute pancreatitis are based on the Western population
disease pattern24. Severe disease is characterized
by organ failure and/or local estimate 20% to 30%
of all patients will have a severe clinical course of
the complications such as necrosis, pseudocyst
or abscess1, 15 and 95% of deaths will occur in this
subset1, 2.
In this study, a significant number of patients
(25.2%) developed organ dysfunction or local
complications. The characteristics of acute pancreatitis
in the patients studied were not different when
compared to the west with regards to the severity of the
disease and the nature of complications13.
The precise mortality rate from acute
pancreatitis is difficult to ascertain due to variations in
diagnostic threshold and inconsistent use of autopsy
data. It is generally reported that the overall mortality of
acute pancreatitis is 5-10% and may increase to 35% or
higher if complications develop7, 13, 25, 26.
DISTRIBUTION OF ETIOLOGY
50
39
12
6
0
10
20
30
40
50
60
ID
IO
PATH
IC
G
ALLSTO
NES
ALCO
HO
L
O
TH
ER
S
ETIOLOGY
NUMBER(n)
Figure III: Showing Various Etiological
Factors Associated with Acute Pancreatitis
The mortality rate of 8.4% in this review
is comparable with other reports from the west13, 27,
where the mortality rate is in the range of 2-9% for all
cases of acute pancreatitis, but lower than those
observed by Taj A et al (20%)14 and Mirza SM et al
(21.2%)16 which may be due to our protocol to admit
every patient with severe acute pancreatitis in intensive
care/high dependency unit; however it is relevant to
recognize that there are many compounding factors,
including the age of the patient, coexisting medical
problems, amount of pancreatic necrosis and infection
of the pancreatic necrosis. The majority (80%) of
deaths among those with acute pancreatitis are due
septic complications as a consequence of bacterial
infection of pancreatic necrosis25. In our study, two
patients had pancreatic necrosis and only one patient
developed pancreatic abscess.
Conclusion
In conclusion, due to increasing incidence of
acute pancreatits, guidelines need to be implemented
after all patients are classified on Ranson’s scoring and
referred to a specialized unit for managing pancreatitis
or other complications requiring intensive care,

5. Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad, Pakistan. Zakaur Rab Siddiqui et al
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 5
radiological, endoscopic or surgical procedures in order
to reduce the high morbidity and mortality14, 24, 26.
As the present approach to identifying the
etiological factor in them is not effective and a more
sensitive investigative tool may have to be considered.
Identifying the etiological factor may have a significant
impact on patient management and prevent recurrence
of the disease. The type of complications and extent of
severe acute pancreatitis are similar in the developing
country like Pakistan to that reported in developed
countries and appropriate management strategies must
be adopted for better outcome.
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