This document discusses the diagnosis and management of acute pancreatitis (AP). It notes that AP is diagnosed based on clinical findings and a threefold or higher elevation of amylase and lipase levels. Imaging like ultrasound and CT can identify complications like necrosis, fluid collections, and alternate diagnoses. Severity is assessed using criteria like Ranson's or modified Glasgow. Mild AP is managed with supportive care like NPO and IV fluids, while severe AP requires intensive care, aggressive resuscitation, antibiotics, and monitoring for organ failure. Complications like pseudocysts may require endoscopic or surgical drainage.

1. MODERATOR – Dr.Basavaraj
CHAIR PERSON – Dr.Rajanna
Presented by Dr.Anuraj

2.  LAB tests
 Diagnosis of AP- clinical findings+ elevation
of pancreatic enzyme levels in the plasma
 threefold or higher elevation of amylase and
lipase levels confirms the diagnosis.

3.  SERUM AMYLASE
 Normal value 23-85U/L
 IF >4 times normal levels (>450 U/L)
 Normal levels do not exclude AP esp. if
patient present 48 hrs later
 Less sensitivity and specificity

5. SERUM LIPASE
Normal value 0-160 U/L
If elevated (>400 U/L) likely indicate pancreatic
damage or pancreatitis
rises 4 to 8 hours from the onset of symptoms
and normalizes within 7 to 14 days after
treatment

6.  CBC: neutrophil leucocytosis
 Electrolyte abnormalities include hypokaemia,
hypocalcemia
 Elevated LDH in biliary disease
 Glycosuria ( 10% of cases)
 Blood sugar: hyperglycaemia in severe cases
 Serum phosphate
 LFTs
 RFTs
 CRP

7. To RULE OUT other conditions, such
as perforated ulcer disease.
 Nonspecific findings
-cutoff colon sign gaseous distension seen in
proximal colon associated with with
narrowing of the splenic flexure
-Widening of the duodenal C loop caused by
severe pancreatic head edema
- complications of lung such as pleural effusion, pulmonary
edema and interstitial inflammation.

8.  to find an enlarged pancreas, a pseudocyst, ascites, biliary
stone, dilated common bile duct and other pancreatic mass
 The usefulness of ultrasound to diagnose
pancreatitis is limited by intra-abdominal fat and
increased intestinal gas as a result of the ileus.
However USG should be ordered because of
high sensitivity in diagnosing gallstones

9. Contrast enhanced CT
 If the patient has…..
◦ Signs of severe acute pancreatitis
◦ No signs of clinical improvement after several days
◦ Diagnostic dilemma
◦ Infection suspected
 T > 101o F
 Positive blood cultures
 What are you looking for?
◦ Necrosis: Lack of enhancement with contrast
◦ Fluid Collections
◦ Alternate diagnosis
Acute Pancreatitis

10.  Pancreas
◦ Pancreatic enlargement
◦ Decreased density due to edema
◦ Intrapancreatic fluid collections
◦ Blurring of gland margins due to inflammation
 Peripancreatic
◦ Fluid collections and stranding densities
◦ Thickening of retroperitoneal fat
Acute Pancreatitis
* It may take up to 72h for inflammatory changes to become apparent on CT *

11. Acute Pancreatitis
Tail Indistinct
Intraperitoneal fluid

12. Acute Pancreatitis
Peripancreatic edema
and inflammation
Unenhancing
Necrosis

13. Acute Pancreatitis
Normal Pancreas

15.  useful to evaluate the extent of necrosis,
inflammation, and presence
of free fluid.
 Cost and availability limits its applicability
 Not indicated in the acute setting of AP
 unexplained or recurrent pancreatitis - the biliary
and pancreatic duct anatomy.To rule out
pancreas divisum, intraductal
papillary mucinous neoplasm (IPMN),
small tumor in the pancreatic duct.

16.  Assessment of severity of disease
RANSON’S CRITERIA
MODIFIED GLASGOW CRITERIA
ATLANTA classification
Acute Physiology and Chronic Health
Evaluation (APACHE II)

17.  For non-gallstone pancreatitis, the parameters are:
 At admission:
 Age in years > 55 years
 White blood cell count > 16000 cells/mm3
 Blood glucose> 10 mmol/L (> 200 mg/dL)
 Serum AST > 250 IU/L
 Serum LDH > 350 IU/L
 Within 48 hours:
 Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
 Hematocrit fall > 10%
 Oxygen (hypoxemia PaO2 < 60 mmHg)
 BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV
fluid hydration
 Base deficit (negative base excess) > 4 mEq/L
 Sequestration of fluids > 6 L

18.  For gallstone pancreatitis, the parameters are:
 At admission:
 Age in years > 70 years
 White blood cell count > 18000 cells/mm3
 Blood glucose > 12.2 mmol/L (> 220 mg/dL)
 Serum AST > 250 IU/L
 Serum LDH > 400 IU/L
 Within 48 hours:
 Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
 Hematocrit fall > 10%
 Oxygen (hypoxemia PaO2 < 60 mmHg)
 BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV
fluid hydration
 Base deficit (negative base excess) > 5 mEq/L
 Sequestration of fluids > 4 L

19. Acute Pancreatitis
MORTALITY
MORBIDITY *
† Sn 73%, Sp
77%
* > 7 d in ICU

22.  Management depends on SEVERITY
MILD ACUTE PANCREATITIS
Acute pancreatitis
No dysfunction of organ or local complications
Ranson’s score <3
or CT grading: A, B, C or CTSI <2
SEVERE ACUTE PANCREATITIS
 Acute pancreatitis
 Local complications
 or organ failure
 or Ranson’s score >3
 or CT grading: D, E or CTSI >3.

23.  Supportive care,fluid resuscitation and
electrolyte balance
NPO with i.v. fluids and electrolytes
 Analgesia
Morphine
 Nutrition
If unable to meet adequate protein and calorie
needs within 5 days ->nasoenteric feeding

24.  Antibiotics
Routine antibiotics not recommended
General recommendations for use:
◦ Biliary pancreatitis with signs of cholangitis
◦ > 30% necrosis on CT scan
OPERATIVE MANAGEMENT
◦ Early cholecystectomy once symptoms have
subsided and cholestatic liver enzymes have
returned to normal in GALLSTONE PANCREATITIS
◦ If cholestatic enzymes not returned to normal
then suspect choledocholithiasis and do ERCP

25.  Mainstay of management is
Early diagnosis
Aggressive resuscitation
Staging by clinical scoring systems
Radiologic imaging

26.  Admission to ICU
 Aggressive fluid resuscitation
 Analgesia
 Invasive monitoring of vitals,CVP,urine
output,blood gases
 Nasogastric aspiration
 Frequent monitoring of lab investigations
 Antibiotics - imipenem
 Supportive therapy for organ failure
 ERCP if cholangitis

27.  Timing of cholecystectomy
Should be delayed until patient is
stabilised,pseudocyst resolves or if it persists
beyond 6 weeks then drained concomitantly
at time of cholecystectomy

28.  Infected necrosis
◦ Organisms on gram
stain after aspirate
◦ Surgical drainage
◦ Trans-gastric drainage
◦ Try to delay
necrosectomy 2-3wk
for demarcation of
necrosis
 Pancreatic abscess
◦ CT or EUS guided
drainage
 Walled collection of
pus
 Similar to
management of
pseudocyst
Acute Pancreatitis

29.  Open
 Endoscopic transluminal
Once necrosectomy is completed,further
necrotic tissue may form
-Closed continuous lavage(Beger)
-Closed drainage
-Open packing
-Closure and relaporotomy

31.  Collection of pancreatic fluid enclosed by wall
of granulation tissue
 Complicates 5-10% cases of AP
 Usually 4 weeks after attack The diagnosis is
corroborated with by CT
 25-50% resolve spontaneously
Acute Pancreatitis

32.  Infection - 14%
 Rupture - 6.8%
 Hemorrhage - 6.5%
 Common bile duct obstruction - 6.3%
 GI obstruction - 2.6%
Acute Pancreatitis

33.  Observation for asymptomatic patients
spontaneous regression has been documented
in up to 70% of cases
 Invasive therapies are indicated for
symptomatic patients or when the
differentiation between a cystic neoplasm and
pseudocyst is not possible.

34.  Percutaneous
 endoscopic drainage
 Surgical drainage is indicated for patients
with pancreatic pseudocysts that cannot be
treated with endoscopic techniques and
patients who fail endoscopic treatment
-cystogastrostomy
-cystoduodenostomy

35. Acute Pancreatitis

36. Acute Pancreatitis
Open
Cystgastrostom
y

37. Acute Pancreatitis

39.  Bailey and love’s
 Sabiston textbook of surgery
 Shackelford’s surgery of alimentary tract