Lecture on acute pancreatitis for medical students. Encompasses basic sciences, classifications, principles and tips of management for this potentially deadly condition.

1. Acute pancreatitis
Chea Chan Hooi
Surgeon
Sibu Hospital

2. Content
• Epidemiology
• Etiology
• Types
• Clinical feature
– Diagnosis
– Severity
– Complications
• Investigations
• Principles of management

3. Epidemiology
• 5 – 80 per 100,000 population
• Age-related demographics
– Biliary tract–related 69 years
– Trauma-related 66 years
– ERCP-related 58 years
– Drug-induced 42 years
– Alcohol-related 39 years
– AIDS-related 31 years
– Vasculitis-related 36 years
• Hospitalization rates increase with age
• Developed nations  gallstone, developing nations 
alcohol

4. Etiology

5. Types
• Interstitial
– Usually diffuse
– Symptoms usually resolve within a week
• Necrotising
– Impairment of pancreatic perfusion
– Sequelae
• Remain solid or liquefy
• Remain sterile or become infected
• Persist
• Resolve over time

6. Diagnosis
• Clinical – Abdominal pain, severe, epigastric,
radiating to the back
• Biochemical – Serum amylase/lipase 3x ULN
• Imaging – USG, CT or MRI findings suggestive
of pancreatic inflammation
• 2/3

7. Severity
• Mild
– Rapid improvement, no organ failure/local or systemic complications
– Can be discharged during early phase
– No need imaging
– Mortality is rare
• Moderately severe
– Transient OF or complications, without persistent OF
– May resolve without intervention but usually needs prolonged
hospitalisation
• Severe
– Persistent OF (>48 hrs)
– Local complications
– Highest mortality seen in severe pancreatitis within first few days
– Infected necrosis worsens

8. Complications
Local
• Acute peripancreatic fluid
collection
• Pancreatic pseudocyst
• Acute necrotic collection
• Walled-off necrosis
• Others
• Splenic and portal vein
thrombosis
• Colonic necrosis
• Pancreatic ascites, pleural
effusion, pericardial effusion
Systemic
• Organ failure
– Respiratory
– Renal
– Hepatic
– CNS
– Cardiovascular

9. Investigations
Radiological
• USG
– Gallstone pancreatitis
– Gross features of local
complications
– TRO differential diagnoses in
ambiguous cases
• CT scan
– TRO differential diagnoses in
ambiguous cases
– Failure to respond to
treatment
Laboratory
• FBC
• RP
• PT/PTT
• LFT
• Minor electrolytes
• Blood, urine C+S

10. Risk stratification
• Clinical
– Elderly, obese
– SIRS
– Moderately severe
• Scoring systems
– Ranson score
– Glasgow Score
– APACHE systems, POSSUM score
• Laboratory
– CRP
– Calcium
– Procalcitonin

11. Principles of management
• Resuscitate
• HDU or ICU care
– Patients at high risk of deterioration
• Individualised treatment
• Nutrition
– Mild  allow orally once symptoms controlled
– Moderately severe & severe  aim to establish
enteral feeds within 48 hours once haemodynamics
stabilised
• Antibiotics
– No role for prophylactic antibiotics

12. • ERCP
– Only in biliary pancreatitis + ascending cholangitis
• Lap cholecystectomy if biliary pancreatitis
– Mild cases, within same admission
– Otherwise, await for collections to resolve/≥ 6
weeks later

13. • Necrotising pancreatitis
– Balthazar index on CT scan
– Management similar to severe interstitial pancreatitis
– Antibiotics only if documented infection
– Intervene if
• SOL effect
– GOO
– Intestinal or biliary obstruction
– Arbitrarily > 4 weeks after onset of pancreatitis for WOPN
• Disconnected duct syndrome
– PD totally transected + sterile necrosis + persisting symptoms
• Ongoing organ failure for several
• Abdominal compartment syndrome
• Ongoing acute bleeding
• Bowel ischemia

14. • Preferred modality of intervention
– Image-guided retroperitoneal percutaneous drain
(1st choice)
– Endoscopic transluminal drain
– Endoscopic necrosectomy
– Surgical necrosectomy
• Laparoscopic
• Open

15. TQ!
Q&A?