Acute Pancreatitis Definition, Etialogy and pathogenesis Atlanta Revised classification Initial risk assesment Management of general condition, local and systemic complications BISAP score Modified Marshall score

1. Acute
Pancreatitis
ATLANTA Classification &
Management
Seneeth Peramuna
Final year medical student
2015-Jun

2. Definition
• Acute pancreatitis is an inflammatory
condition of the pancreas, clinically
characterized by acute abdominal pain and
elevated levels of pancreatic enzymes in the
blood

3. Pathogenesis
• Auto digestion of pancreatic substance by
inappropriately activated pancreatic enzymes
(especially trypsinogen)

4. Etiology
• Gallstones (30 – 40%)
• Alcohol
• Hypertriglyceridemia
• ERCP
• Smoking
• Drugs
• Infections
• Trauma
• Vascular disease

5. Diagnosis
• Most often established by the presence of two of the three following criteria:
(i) abdominal pain consistent with the disease,
(ii) serum amylase and/or lipase greater than three times
the upper limit of normal, and/or
(iii) characteristic findings from abdominal imaging.
_________________________________________________________
CT and/or MRI of the pancreas should be reserved for patients
– in diagnostic uncertainty (typical pain with normal enzymes)
– In severe AP to distinguish interstitial from necrotizing pancreatitis
– who fail to improve clinically within the first 72 h after hospital admission
– to evaluate local complications

6. • No organ failure
• No local complicationsMild
• Transient organ failure <48hrs
• Local complications +/-Moderate
• Persistent organ failure >48hrsSevere
* Local complications : acute peripancreatic fluid collection, pancreatic pseudo cyst,
acute necrotic collection, pleural effusion
* Organ failure : failure of 3 main organs, respiratory, cardiac, renal
and other organ systems ( hepatic, hematological, Neurological)
Classification of acute pancreatitis – Revised ATLANTA criteria 2012

7. Initial Management
Initial assessment and risk stratification,
ICU care warrant if AP with,
• Pulse <40 or > 150 / min
• SBP <80 mmHg or DBP >120mmHg
• RR > 35 cycles/min
• Severe electrolyte imbalance
• Severe acidosis or alkalosis
• Glucose >800 mg/dl
• Anuria
• coma

8. Initial Management
Fluid
• 10-20ml/kg/hr
isotonic
crystalloid
(Hartmann
preferred)
• Monitor 6 hourly
for volume
overload and
UOP >
0.5ml/kg/hr
• in 1st 12 - 24 hrs
• If not :
Necrotizing
pancreatitis
Pain management
• Fentanyl/
Pethidine
preferred over
morphine
• If not :
hemodynamic
instability
Monitoring
• SpO2 and ABG
• UOP
• Electrolytes
including Ca+2 and
Mg+2
• Blood glucose
• If in ICU : bladder
pressure ( for
Abdominal
compartment Xd)
Nutrition and
Antibiotics
• Nutrition,
Nasogastric
feeding is
preferred as
Nasojejunal
feeding over TPN,
provided patient
is tolerating
• Antibiotics, Start
on suspicion and
omit if cultures
negative

9. Management of Local complications
• Pleural effusion/ Peripancreatic fluid collection
– No special intervention needed
• Pancreatic necrosis
– CT guided aspiration, Culture & ABST
– Start in Antibiotics – Carbapenams + metraniadazole
– Percutaneous CT guided catheter drainage/ Necrostomy
• Peripancreatic vascular complications
– Splanchnic venous thrombosis – resolve spontaneously, but if symptomatic,
Anticoagulation
• Abdominal compartment syndrome
– Sustained intra abdominal pressure >20mmHg with new onset organ failure,
due to tissue edema, peripancreatic inflammation & ascites
– careful observation and supportive care, abdominal compartment
decompression may required

10. Management of systemic
complications
• Careful for exacerbations of underlying co
morbidities ( CAD, Chronic lung disease)
• Treat for alcohol withdrawal if necessary
• Educate on diabetes risk and lifestyle
modifications

11. Management of etiology
1. Gall stone pancreatitis
– If suspected ERCP within 1st 24 hrs
– Cholecystectomy performed after recovery
2. Advise on alcohol abstinence
3. Hypertriglyceridemia
– risk for pancreatitis when levels are >1000 mg/dL
– therapeutic plasma exchange (TPE)

12. Summery
• Definition
• Etiology & pathogenesis
• Revised ATLANTA classification
• Initial risk assessment
• Management according to Fluid, Pain,
Monitoring, Nutrition and antibiotics
• Management of local and systemic
complications
• Management of common etiological factors

13. References
• Up todate.com
• Classification of acute pancreatitis—2012: revision of the Atlanta Classification and
definitions by international consensus
http://www.nghd.pt/nghd/images/stories/classification_of_pancreatitis.pdf
• American association of Gastroenterologists' guidelines 2013

14. Thank you !

15. BISAP score
• BUN >25 mg/dL (8.9 mmol/L) (1 point)BUN
• Abnormal mental status with a Glasgow
coma score <15 (1 point)
Impaired mental
status
• Evidence of SIRS (systemic inflammatory
response syndrome) (1 point)SIRS
• age >60 years old (1 point)Age
• Imaging study reveals pleural effusion (1
point)Pleural effusion
0-2 Points: Lower mortality (<2 percent)
3-5 Points: Higher mortality (>15 percent

16. Modified Marshall score