Acute

Pancreatitis
Acute, reversible inflammatory process
of the pancreas

Case Study
A 55-year-old man presents to the emergency
department complaining of severe midepigastric abdominal pain that radiates to the
back. The pain improves when the patient leans
forwards and worsens with lying supine and
movement.
He also complains of nausea, vomiting, and
anorexia, and had a history of heavy alcoholic
intake this past week.

 On examination, he is tachycardic, tachypnoeic,

and febrile with hypotension.
Abdominal distension, epigastric tenderness
with abdominal guarding

PRESENTATION
WBC : 19.1, Platelet: 289, Hematocrit: 41% (40-54)
Serum Lipase: 2211 (0160 U/L)
Serum Amylase: 804 (40140 U/L)
ALT:10 (<41 U/L), AST: 9 (<40 U/L), ALP:79 (15-129 U/L)
Ca: 8.0 (8.410.2 mg/dL)
TGs: 511 (0149 mg/dL)
Creatinine: 70 (53-106 mmol/L)
ABG : pH 7.33, PaO2 80 mmHg

Acute Pancreatitis: Pathophysiology

INFLAMMATIONOF THE PANCREAS
Inappropriate activation of pancreatic enzymes
Intraparenchymal and extraparenchymal extravasation
of enzymes cause auto-digestion of pancreatic
parenchyma and damage to peri-pancreatic tissues and
vascular network
Pancreatic enzymes cause extensive local damage as well as
activation of complement and cytokine systems
Inflammatory response causes further damage
Fluid sequestration, fat necrosis, vasculitis, leading to
occlusions and thrombosis, hemorrhage SIRS ( Shock, ARDS,DIC,
Renal failure)

Aetiology
I - Idiopathic
G - Gallstones
E - Ethanol (Alcohol)
T - Trauma

S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion venom
H - Hyperlipidemia, Hypercalcemia
E - ERCP and emboli
D - Drugs

Clinical features
Abdominal pain (usually epigastric/diffuse upper quadrant)
- May radiate to the back, relieved by leaning forward
Nausea
Vomiting
Anorexia
Low grade fever
Less common signs:
Cullens sign (Peri-umbilical blue discoloration)
Grey Turner sign (Bilateral flank blue discoloration indicating
haemorrhagic pancreatitis)

Physical Examination

General (Distressed, anxious, ill-looking)

Vital signs (Fever/tachycardia/tachypnoea/hypotension)
Sclera: Mild jaundice (biliary obstruction)
Abdomen: Tenderness, guarding, distension
Diminished/absent bowel sound
Mass maybe palpable (pseudocyst)

Pleural effusion (10-20%)

Signs of hypocalcemia may present:
- Chvosteks sign (Facial muscle spasm when facial nerve is tapped)
- Trousseaus sign (Carpopedal spasm when blood pressure cuff is
applied)

Differential diagnosis
Differential diagnosis

Characteristics

Peptic Ulcer Disease

Longstanding epigastric pain, which does not

generally radiate to the back; reflux; heartburn; and
anorexia. Identifiable causes such as non-steroidal
anti-inflammatory drug (NSAID) use, Helicobacter
pylori may present.

Intestinal Obstruction

-History of abdominal surgeries (especially colon

resection, caesarean sections, and aortic
procedures).
-Hernias in the physical examination.
-Presents with abdominal distension (depends on
the level of obstruction), tympanism, decreased
bowel sounds, anorexia, emesis (quality depends on
location of obstruction), or constipation.

Differential diagnosis

Characteristics

Cholangitis

Charcot's triad (jaundice, right upper quadrant

pain, and fever) present in 70% of patients, altered
mental status, and hypotension indicate biliary
sepsis.

Choledocholithiasis

Severe right upper quadrant pain of sudden onset,

jaundice, and hx of cholelithiasis. May occlude the
common bile duct and cause pancreatitis.

Viral Gasteroenteritis

Generalised non-specific abdominal pain,

anorexia, nausea, emesis, diarrhoea, and
dehydration.

Hepatitis

Jaundice, right upper quadrant pain, anorexia, and

general malaise.
Examination: tenderness to palpation over the right
upper quadrant and enlarged liver.

Assessment of severity
Severity of acute pancreatitisis commonly assessed using :
1. Ransons Criteria
5 clinical signs at presentation on admission and at 48hrs
3 associated with severe course (systemic complications
and/or pancreatic necrosis)
2. Glasgow Criteria
3. APACHE II
12 routine physiologic measurement, age and previous
health status
8 associated with severe course

Ransons Criteria
At Admission
Age >55 yrs

WBC >15 x 109

Blood Glucose > 10 mmol/L
Serum LDH >600 IU/L
AST >200 IU/L

Initial 48 Hours

Hematocrit decrease >10%

BUN elevation >10 mmol/L
Serum Ca <2 mmol/L
Arterial PO2 <60 mmHg
Base Deficit >4 mEq/L
Fluid sequestration >6L

Glasgow Criteria

PaO2 Oxygen < 60mmHg or 7.9kPa

Age > 55
Neutrophilia ,White blood cells > 15
Calcium < 2 mmol/L
Renal Urea > 16 mmol/L
Enzymes: Lactate dehydrogenase (LDH) > 600 IU/L Aspartate
transaminase (AST) > 200 IU/L
Albumin < 32 g/L
Sugar Glucose > 10 mmol/L

Apache II
Physiological

Laboratory

Temperature
Heart rate
Respiratory rate
Mean arterial pressure
GCS

PaO2
Arterial Ph
Serum (Na, K, Cr)
Hematocrit
WBC

Investigation
Serum Amylase (40-140 U/L)
- elevated 2-12 hrs following onset of symptoms
- 2-3 x upper limit

Serum Calcium
- Fall as a result of complexing w/ fatty acids

Serum Lipase (0-160 U/L)

- More specific for pancreatic disease
- 2x normal range

Urinary Amylase (24-400 U/L)

- >5000 IU/ 24 hrs

FBC, Renal Profile, LFT, Fasting lipid

Role of Radiology in Acute Pancreatitis

Rule out other intraabdominal conditions as cause of
abdominal pain or other symptoms
Bowel obstruction, infarction or perforation; acute
cholecystitis; appendicitis

Confirm diagnosis and Identify causes(e.g. gallstones)

Evaluate and stage local pancreatic morphology
Identify and manage complications

Imaging
Plain Abdominal x-ray
Screen for/exclude separate or accompanying abdominal
process
- Signs of peritonitis or bowel ischemia
Free air
- Bowel Obstruction
Abdominal ultrasound
Excellent for identifying gallbladder pathology, and gallstones
(Most common cause of pancreatitis!)
Evaluate bileduct dilation
May visualize masses and follow up of pseudocyst

 CT Scan
Aid in diagnosis and staging of pancreatitis
Depict, quantify pancreatic parenchymal injury
Ability to assess the presence or absence of:
Edema (focal or diffuse)
Peripancreatic fluid and inflammation
Fluid collections
Pseudocysts
Necrosis

Management
Fluid resuscitation and correction of electrolyte
imbalance
Analgesia
Bowel rest (Keep Nil By Mouth)
Stress ulcer prophylaxis (PPI)
Treat underlying cause : eg. Cholecystectomy, avoidance
of alcohol intake

 Mild pancreatitis in 80-90% of cases

Most resolve in 5-7 days on average
Gallstone induced pancreatitis may benefit from
ERCP and stone removal
Severe Pancreatitis in remaining 10-20%
(clinical indicators suggestive of severe disease
include peritonitis, shock, respiratory distress)

Severe Acute Pancreatitis

Admission to ICU
Nasogastric drainage
Oxygen supplementation
Fluid resuscitation
Close monitoring of vital signs, CVP, urine output, ABG,
hematological and biochemical parameters
Analgesia
Nutritional support
CT scan
Immediate ERCP : Gallstone pancreatitis/sign of cholangitis

Complications
Acute Pancreatic Fluid Collection
Pancreatic Necrosis
Pancreatic Pseudocyst
Pancreatic Abscess

References
H. George Burkitt, Essential Surgery, 4th Ed. Churchill
Livingstone
Acute Pancreatitis, British Medical Journal
Balthazar, E J, Acute Pancreatitis: Assessment of Severity with
Clinical and CT Evaluation. Radiology 2002; 223:603 613