This document provides an overview of acute pancreatitis, including its definition, epidemiology, causes, signs and symptoms, diagnostic tests, treatment, and complications. It notes that acute pancreatitis results from inflammation of the pancreas that can range from mild to severe. Diagnostic testing includes blood tests, imaging like ultrasound, CT, and MRI to determine severity. Treatment involves supportive care, pain management, fluid resuscitation, and treating any underlying causes or complications like infection if they develop.

1. Acute Pancreatitis
• Dr LNR González
• Robert Mangaliso Sobukwe Hospital(Kimberley Hospital)2019

2. Acute Pancreatitis
Definition
Epidemiology
Aetiology
Signs & Symptoms
Investigations
Management
Complications

3. Acute Pancreatitis
Definition:
• Acute inflammation of the pancreas(and, sometimes , adjacent
tissues).
• Reversible inflammation .
• Ranges from mild to severe .

4. Epidemiology
• Acute pancreatitis accounts for 3% of all cases of abdominal pain of
all patients admitted to hospital.
• Affects 2-28 per 100000 population.
• It may occur at any age , peak incidence is between 50-60 years of
age.
• Women are affected more than men , but men are more likely to
suffer from recurring attacks.

5. Aetiology
Mnemonic : GET SMASHED
• G- allstones (40%)
• E- thanol (40%)
• T- rauma (1.5%)
• S- teroids
• M- umps
• A- utoimmune
• S- corpion venom
• H- yperlipidemia , Hypothermia , Hypercalcemia
• E- RCP (5%), Emboli
• D- rugs
NOTE: Pregnancy , Neoplasia or No Known Cause (10-30%)

6. Symptoms
• Gradual or sudden severe epigastric or central abdominal pain which
radiates to the back and shoulder tips, relieved by leaning forward.
• Patient tends to lie very still.
• Nausea
• Vomiting
• Retching
• Weakness

7. Signs
• Tachycardia
• Tachypnoea
• Shallow Breathing
• Diaphoresis
• Hypotension
• Mild Icterus
• Fever
• Shock
• Ileus
• Rigid abdomen +/- local/general tenderness
• Periumbilical bruising (Cullen’s Sign) or on flanks (Grey Turner’s sign) from blood vessel autodigestion and
retroperitoneal haemorrhage.
• Bruising is seen over the inguinal ligament ( Fox’s sign) , occurs in patients with retroperitoneal bleeding,
usually due to acute hemorrhagic pancreatitis.

8. Differential Diagnosis
• Peptic ulcer
• Perforated Viscus
• Acute Cholecystitis , Biliary Cholic
• Acute Intestinal Obstruction
• Oesophageal Rupture
• Mesenteric Vascular Obstruction
• Renal Colic
• Dissecting Aortic Aneurism
• MI
• Basal Pneumonia
• DKA

9. Investigations
Should be aimed at answering 3 questions:
1. Is the diagnosis of acute pancreatitis correct?
2. How severe is the attack?
3. What is the aetiology?

10. Investigations
Blood Tests:
• FBC
• Serum amylase and lipase
• C-reactive protein
• Serum electrolytes
• Blood glucose
• Renal function test
• LFT
• LDH
• Clotting profile
• ABG

11. Serum Amylase
• Sensitivity: 72% Specificity:99%
• Released with 6-12 hours of the onset & remains elevated for 3-5
days.
• Elevation of >3 x normal is significant.
• Undergoes renal clearance. After its serum level decline , its urine
level remain elevated.
• Its level doesn’t correlate with the disease activity

12. Serum Lipase
• More pancreatic-specific than Serum Amylase.
• Sensitivity: 100% Specificity: 96%
• Remains elevated longer than amylase ( about 1 week)
• Useful in patients presenting late to the physician.
• S.Amylase tends to be higher in Gall Stone Pancreatitis.
• S.Lipase tends to be higher in Alcoholic Pancreatitis.

13. Imaging Investigations : X-Rays
Erect CXR :
• Not diagnostic but helps to rule out DDx.
AXR :
• Calcification in the pancreas
• Mass from a pseudocyst
• Sentinel loop: a single dilated jejunal loop in the upper abdomen
• Colon cut off: dilated colon to the mid-transverse colon with no air seen
beyond the splenic flexure. This is due to extension of inflammation along
mesocolon.
• Diffuse ileus (smalll bowel dilatation) is most common

14. Sentinel Loop Sign

15. Colon Cut-Off Sign
• Cut off sign and Ileus
• White arrow points to
Transverse Colon cut off
at Splenic flexure. No air
in descending colon.
• TC: Transverse colon
• I: Represents small bowel
loops with air suggestive
of Ileus

16. Imaging Investigations : Ultrasound
Findings:
• Edematous
pancreas
• Gallstones
• Dilated common
bile duct
• Pseudocyst
• When ileus is
present pancreas Is
poorly defined

17. Imaging Investigations: CT Scan
Contrast-enhanced CT of the pancreas is diagnostic and can show:
• Enlargement of pancreas due to edema
• Peripancreatic inflammation.
• Necrosis: On contrast enhanced phases the necrotic pancreatic parenchyma will
show decreased or no enhancement when compared with normally enhancing
viable tissue
• Fluid collections: A simple peripancreatic fluid collection will not have a well-
defined capsule
• Pseudocysts: As liquefaction of necrotic pancreatic tissue progresses it will
gradually take on the appearance of localized fluid collection - pseudocyst
• Abscesses: Diffusely enlarged pancreas with air pockets
• Hemorrhagic pancreatitis: Enlarged pancreas with increased density due to
hemorrhage

18. Acute Pancreatitis CT
• CT Findings: Post
Contrast
• Diffusely enlarged
pancreas with low
density from
edema
• C: Colon
St: Stomach
P: Pancreas

19. Acute Haemorrhagic Pancreatitis
• Enlarged tail of
pancreas
• White arrow:
Increased density
in the enlarged tail
of pancreas due to
blood
• Fascial changes
adjacent to tail of
Pancreas due to
inflammation

20. CT Severity Index
Combines the Balthazar grade
(0-4 points) with the extent of
pancreatic necrosis (0-6 points)
on a 10-point severity scale.
• 0-1 = 0% Mortality
• 2-3 = 3% Mortality
• 4-6 = 6% Mortality
• 7-10 = 17% Mortality

21. Imaging Investigations : MRI
The advantages of MRI over CT :
• Lack of nephrotoxicity of gadolium.
• Ability of MRI to better categorize
fluid collection as acute fluid
collections, necrosis ,abscess,
haemorrhage, and pseudocyst.
• Greater sensitivity of MRI to
detect mild acute pancreatitis
compared to CT.
• MRI delineates the pancreatic and
bile ducts better and is
comparable to ERCP for the
detection of choledocholithiasis.

22. Management : Goals of Treatment
• Aggressive supportive care
• Decrease inflammation
• Limit Superinfection
• Identify and treat complications
• Treat cause if possible

23. Conservative Management
• Gain IV access
• Obtain blood sample
• Rapid fluid resuscitation
• Electrolyte management
• Give analgesics (IM pethidine)
• Give anti-emetics
• Keep patient NPO (until pain free 2-3 days)
• NGT insertion to relieve vomiting
• Urinary catheterization
• Monitor vitals
• PPI IV

24. Management of Severe Acute Pancreatitis
• Ideally admission to ICU
• Analgesia
• Aggressive fluid resuscitation
• Oxygenation
• Invasive monitoring of vital signs , central venous pressure , urine
output , ABG.
• Frequent parameters of chemical and biological parameters ( Liver
and renal function tests , clotting , serum calcium , blood glucose)
• Nasogastric tube
• CT scan essential if organ failure , clinical deterioration or signs of
sepsis develop
• Supportive failure for organ failure if it develops( inotropes ,
ventilatory support, HD, etc)
• If nutritional support is required, consider enteral feeding.

25. Role of Antibiotics
 Prophylactic antibiotics have shown NO DECREASE of mortality in
severe acute pancreatitis.
Antibiotics are justified if :
1. Gas in retroperitoneal space
2. Needle aspiration of necrotic material confirms infection
3. Sepsis
4. CRP of >120mg/L
5. Peri-pancreatic fluid collection
6. Organ dysfunction
7. APACHE II Score of >6 ( Estimates ICU mortality based on a
number of laboratory values and patient signs taking both acute
and chronic disease into account)

26. Operative Management
• Surgery has NO IMMEDIATE ROLE in acute pancreatitis.
• Aggressive surgical pancreatic debridement should be undertaken
soon after confirmation of the presence of infected necrosis.

27. Systemic Complications
• Cardiovascular : Shock , Arrythmias , Pericardial Effusion.
• Pulmonary: Basal Atelectasis , Pleural Effusion, ARDS.
• Renal: Acute Kidney Injury.
• Haematological: DIC
• Metabolic: Hypocalcaemia , Hyperglycaemia , Hyperlipidaemia.
• GIT: Ileus
• Neurological: Confusion , Irritability , Encephalopathy.
• Miscellaneous: Subcutaneous Fat Necrosis , Arthralgia.

28. Local Complications
Occur after 1st week :
• Acute fluid collection
• Sterile pancreatic necrosis
• Infected pancreatic necrosis
• Peripancreatic
Pseudoaneurysm
• Pancreatic abscess
• Splenic vein thrombosis

29. References
• Harrison’s , Merck Manual, WSES guidelines, UpToDate, etc
Acute Pancreatitis

30. THANK YOU