The document discusses acute pancreatitis, including causes, clinical features, diagnosis, severity grading, management, and prognosis. Gallstones and alcohol are the most common causes. Scoring systems like Ranson criteria and APACHE II can help indicate severity and prognosis. Management involves treatment of the underlying cause, supportive care, and monitoring for complications like pancreatic necrosis which may require intervention.

2. Gallstones continue to be the most common
cause of acute pancreatitis in most series
Alcohol is the second most common cause

3. "GET SMASH'D"
 Gallstones,
 Ethanol,
 Trauma,
 Steroids,
Mumps,
 Autoimmune,
 Scorpion bites,
 Hyperlipidemia,
 Drugs(azathioprine, diuretics)

5. Abdominal pain
Nausea and vomiting
signs may vary from mild tenderness to
generalised peritonitis.
Grey-Turner's sign
Cullen's sign

6. MOF- Respiratory,cardiovascular failure
&acute renal failure.
Metabolic
(hypocalcaemia,hypomagnesaemia,
hyperglycaemia)
Haematological (DIC)
Fever - systemic inflammation, or acute
cholangitis, due to bacterial infection-LATE

7. a recognised entity
occurs in cases of shock of unknown origin,
during the postoperative period,
in renal transplant
peritoneal dialysis patients,
and in diabetic ketoacidosis.

9. Typical clinical features
+ a high plasma concentration of pancreatic
enzymes
serum amylase concentrations decline quickly
over two to three days
Relate it to onset of abdominal pain

10. several non-pancreatic diseases (visceral
perforation, small bowel obstruction and
ischaemia, leaking aortic aneurysm, ectopic
pregnancy),
tumours also secrete amylase

11. superior sensitivity and specificity
preferable to serum amylase for the
diagnosis of acute pancreatitis

12. History
physical examination,
liver function tests,
and biliary ultrasonography will indicate the
correct cause in most cases.
If not, follow-up investigations, should
include fasting plasma lipids and calcium, viral
antibody titres, and repeat biliary
ultrasonography.

14. detect free air in the abdomen,
colon cut-off sign, a sentinel loop, or an ileus.
calcifications within the pancreas - chronic
pancreatitis.

15. Plain radiographs clues
alternative abdominal emergency,
detect and stage complications of acute
severe pancreatitis, especially pancreatic
necrosis

16. pancreatic necrosis cannot be appreciated
until at least three days after the onset of
symptoms.
Patients with persisting organ failure,
signs of sepsis,
clinical deterioration occurring after an initial
improvement
Follow-up scans

17. also provide prognostic information based on
the following grading scale developed by
Balthazar:
A - Normal
B - Enlargement
C - Peripancreatic inflammation
D - Single fluid collection
E - Multiple fluid collections

18. The chances of infection and death are
virtually nil in grades A and B
steadily increase in grades C through E.
Patients with grade E pancreatitis have a 50%
chance of developing an infection and a 15%
chance of dying.

19.  only be used in the following situations:
 severe acute pancreatitis secondary to stones
 biliary pancreatitis - worsening jaundice and
clinical deterioration despite maximal supportive
therapy.
 with sphincterotomy and stone extraction, may
reduce the length of hospital stay, the
complication rate, and, possibly, the mortality
rate.
 in the setting of suspected SOD (sphincter of
oddi dysfunction)

20.  PRSS1 genetic testing is recommended in symptomatic
patients with any of the following features
 n
 Recurrent attacks of acute pancreatitis for which no cause
has been found
 Idiopathic chronic pancreatitis
 A family history of pancreatitis in a first or second degree
relative
 Unexplained pancreatitis occurring in a child

22.  Supplemental oxygen
 adequate fluid resuscitation
 A urinary catheter
 Central venous monitoring
 All patients with severe acute pancreatitis
should be managed in a high dependency unit or
intensive therapy unit.
 opiate analgesia.
 A nasogastric tube is not useful routinely but
may be helpful if protracted vomiting occurs in
the presence of a radiologically demonstrated
ileus.

23. All patients with severe acute pancreatitis
should be managed in a high dependency
unit or intensive therapy unit with full
monitoring and systems support
(recommendation grade B).

24. no proven therapy for the treatment of acute
pancreatitis.

25. Patients with alcohol-induced pancreatitis
may need alcohol-withdrawal prophylaxis.
Lorazepam, thiamine, folic acid, and multi-vitamins
are generally used in this group of
patients.

27.  imaging of the common bile duct is required.
 If the presence of stones in the common bile duct
is confirmed, a cholecystectomy with common
bile duct exploration (either surgical or
postoperatively with endoscopic retrograde
cholangiopancreatography [ERCP]) should be
performed during the same hospitalisation in
mild to moderate disease soon after the attack
resolves.
 A longer delay, even of a few weeks, is associated
with a high recurrence (80%) of acute pancreatitis
and re-admission

28. If the pancreatitis is severe, some allow a few
months for the inflammation to completely
resolve before performing a cholecystectomy

29. In patients who are not candidates for surgery
because of comorbidities with a high American
Association of Anesthesiology (ASA) index,
sepsis, or severe disease,
 ERCP must be considered.
 Urgent ERCP is indicated in patients with biliary
sepsis and obstructive jaundice that show no
improvement in 48 hours after the onset of the
attack.
 ERCP is a diagnostic and therapeutic
intervention

30. If mild to moderate pancreatitis is found,
cholecystectomy with intra-operative
cholangiogram should be performed but the
pancreas should be left alone.
For severe pancreatitis, the lesser sac should
be opened and the pancreas fully inspected.
Some surgeons place drains and irrigating
catheter around the pancreas.

31. during the same hospital admission,
unless a clear plan has been made for
definitive treatment within the next two
weeks (recommendation grade C).
should be delayed in patients with severe
acute pancreatitis until signs of lung injury
and systemic disturbance have resolved.

33. infected necrosis -high mortality rate (40%).
diagnosed either by the presence of gas
within the pancreatic collection
or by fine needle aspiration

34. All patients with persistent symptoms and >
30% pancreatic necrosis,
and those with smaller areas of necrosis and
clinical suspicion of sepsis,
should undergo image guided fine needle
aspiration to obtain material for culture 7–14
days after the onset of pancreatitis
(recommendation grade B).

35. sterile necrosis - managed conservatively.
infected necrosis -radiological or surgical
intervention.

37. Some trials show benefit, others do not.
 At present there is no consensus on this
issue. If antibiotic prophylaxis is used, it
should be given for a maximum of 14 days

38. rationale -mortality for infected pancreatic
necrosis is higher than that for sterile
necrosis.

40. No conclusive evidence to support the use of
enteral nutrition in all patients with severe
acute pancreatitis.
enteral route is preferred if that can be
tolerated (recommendation grade A).
nasogastric route effective in 80% of cases
(recommendation grade B).

41. The use of enteral feeding may be limited by
ileus. If this persists for more than five days,
parenteral nutrition will be required.

43. clinical impression of severity,
obesity, or APACHE II>8 in the first 24 hours
of admission, and
C reactive protein >150 mg/l,
Glasgow score 3 or more,
or persisting organ failure after 48 hours in
hospital (recommendation grade B).

44. The definitions of severity, as proposed in the
Atlanta criteria, should be used.
organ failure present within the first week,
which resolves within 48 hours, should not be
considered an indicator of a severe attack
(recommendation grade B).

45.  Bradley reported the criteria for severe acute pancreatitis
developed at the International Symposium on Acute Pancreatitis
held in Atlanta, Georgia.
Criteria for severe acute pancreatitis - one or more
of the following:
 (1) Ranson score on admission >= 3 (or during
the first 48 hours)
 (2) APACHE II score >= 8 at any time during
course
 (3) presence of one or more organ failures
 (4) presence of one or more local complications

46. Scoring systems increase accuracy of
prognosis.
Use of the Glasgow Prognostic
Score/Ranson's Criteria/Acute Physiology and
Chronic Health Evaluation II (APACHE II)
score can indicate prognosis, particularly if
combined with measurement of CRP >150
mg/L.

47. Ranson criteria for pancreatitis at
admission LEGAL:
Leukocytes > 15 x109/l
Enzyme AST > 250
units/l
Glucose > 10mmol/l
Age > 55
LDH > 600 units/l

48.  Ranson criteria for pancreatitis: initial 48
hours "C & HOBBS" (Calvin and Hobbes):
 Calcium < 2mmol/l
 Hct drop > 10%
 Oxygen < 8 kpa
 BUN > 1mmol/l
 Base deficit > 4mmol/l
 Sequestration of fluid > 6L

49. NUMBER OF POSITIVE CRITERIA
0-2 <5% mortality
3-4 20% mortality
5-6 40% mortality
7-8 100% mortality

50. uses age, and 7 laboratory values collected
during the first 48 hours following admission,
to predict severe pancreatitis.
It is applicable to both biliary and alcoholic
pancreatitis.
The score can range from 0 to 8. If the score is
>2, the likelihood of severe pancreatitis is
high. If the score is <3, severe pancreatitis is
unlikely.

51. Age >55 years
WBC >15 x 109/L
Urea >16 mmol/L
Glucose >10 mmol/L
pO2 <8 kPa (60 mm Hg)
Albumin <32 g/L
Calcium <2 mmol/L
LDH >600 units/L
AST/ALT >200 units

52.  The majority of patients with acute pancreatitis will
improve within 3 to 7 days of conservative
management.
 The cause should be identified,
 a plan to prevent recurrence should be initiated
before the patient is discharged.
 In gallstone pancreatitis, a cholecystectomy should be
considered before discharge in mild cases and a few
months after the discharge date in patients with
severe symptoms.
 In patients who are not candidates for surgery,
endoscopic retrograde cholangiopancreatography
(ERCP) must be considered.

53. include:
(1) pancreatic necrosis
(2) pancreatic abscess
(3) pancreatic pseudocyst

54. Organ failures include:
 (1) shock (systolic blood pressure less than 90
mm Hg)
 (2) pulmonary insufficiency (PaO2 <= 60 mm Hg
on room air)
 (3) renal failure (serum creatinine > 2 mg/dL after
fluid replacement)
 (4) gastrointestinal bleeding, with > 500 mL
estimated loss within 24 hours
 (5) DIC (thrombocytopenia and
hypofibrinogenemia and fibrin split products)
 (6) severe hypocalemia (<= 7.5 mg/dL)

55. Thanks !