Definition

Acute pancreatitis :
• Defined as Acute inflammatory process of the pancreas that range

from mild interstitial pancreatitis to severe necrotizing pancreatitis.
• It is the most common gastrointestinal disease requiring acute
admission to hospital.
• It is unpredictable and potentially lethal disease.
Causes :
• Gallstones (45%) = biliary pancreatitis = gallstone pancreatitis.
• Alcohol abuse (20 %).
• Idiopathic (10-30 %).
• Other causes including:
-Medications (azathioprine, sulfonamides, tetracycline, valproic acid,
thiazide, estrogens).
-Endoscopic retrograde cholangiopancreatography (ERCP) = post-ERCP
pancreatitis.
-Hypercalcemia.
-Hypertriglyceridemia.
-Infections.
-Genetic mutations.
-Autoimmune pancreatitis.
-Trauma (blunt or postoperative).
Clinical feutures:
Symptoms:
Abdominal pain:
-The major symptom

-Constant and steady
-Epigastric, left upper quadrant or peri umbilical
-Referred to the back
-Increased on supine position
-decreased by sitting and leaning forwards.
-Vary from mild to severe.
-Associated with nausea, vomiting and abdominal distention
General Examination:
• Low grade fever, tachycardia, hypotension or even shock in severe
necrotizing pancreatitis (due to exudation of blood and plasma protein
into retroperitoneal space with hypovolemia).
• Left pleural effusion.
• Jaundice.
Local abdominal examination:

• Abdominal tenderness with distention.
• may be voluntary guarding or rigidity.
• Abdominal ecchymoses around umbilicus (Cullen’s sign) and in both
flanks (Turner’s sign) indicating severe necrotizing pancreatitis with
hemoperitoneum.
• Diminished or absent bowel sounds if ileus (due to chemical
peritonitis).
Laboratory investigations:
• Elevated Serum amylase and or serum lipase (s. amylase return to
normal even with continuous inflammation after 2-3 days, but serum
lipase remains elevated for 7-14 days).
• Leukocytosis, hyperglycemia, hypocalcemia, hypertriglyceridemia.
• Increased serum bilirubin and ALP.
• High ALT and AST may indicate biliary etiology.
High LDH, low serum albumin &high hematocrit > 44% (hemoconcentration)
indicate more severe disease with poor prognosis.
Imaging investigations:
• Abdominal ultrasound: to evaluate the gall bladder for stones.
• Contrast enhanced CT: for detailed evaluation of pancreas and
surrounding structures (necrosis, collections, peudocyst, tumors ,
vascular thromboses)
• MRCP : for noninvasive evaluation of pancreatico- biliary ductal system
( small stones)
• EUS : for better visualisation of pancreatico-biliary ductal system and
pancreatic parenchyma.
Criteria for diagnosis:
The diagnosis of acute pancreatitis is based on the fulfilment of two of three

criteria:
(1) upper abdominal pain.

(2) Elevated serum amylase or lipase (or both) of at least three times the
upper limit of normal.
(3) findings consistent with acute pancreatitis on imaging (contrast-
enhanced CT [CECT], MRI, or abdominal ultrasound).
Complications:
Systemic complications:
1-Pulmonary: ARDS and respiratory failure

2-Cardiovascular: shock
3-Renal: Renal failure
4-Hematological: DIC
5-Gastrointestinal : bleeding
6-CNS : psychosis , fat embolism and encephalopathy
Local complications:
1- The most frequent local complications associated with acute pancreatitis

are pancreatic or peripancreatic fluid collection
2-pancreatic pseudocyst
3-gastric outlet dysfunction
4-splenic or portal vein thrombosis
Pancreatic collection
1- interstitial pancreatitis:
• contain a homogeneous liquid content.
• collections resolve spontaneously over time.
• If these collections persist beyond 4 weeks after onset of acute
pancreatitis, they are referred to as pancreatic pseudocysts.
2- Necrotizing pancreatitis
• contain variable amounts of fluid and necrotic debris.
• Necrosis can involve the pancreatic parenchyma alone but is often
accompanied by the presence of peripancreatic necrosis.
When acute necrotic collections mature and encapsulate, usually after 4
weeks, they are referred to as walled-off necrosis
Classification according to severity :
Mild: no local or systemic complications.

Moderate: local complications or systemic complications, and in the
absence of persistent organ failure.
Severe: persistent single or multiple organ failure, which is associated
mortality rates between 20% and 40%.
Differential diagnosis:
1-Perforated peptic ulcer

2-Acute cholecystitis
3-Acute intestinal obstruction
4-Mesenteric vascular occlusion
5-Acute myocardial infarction
6-Pneumonia
7-DKA
Treatment Outlines:
1-Fluid replacement.
2-Symptomatic treatment
3-Early enteral feeding.
4-Close observation.
5-Antibiotics as needed.
6-Intervention in certain circumstances.
Fluid replacement :
• Rate: Intravenous fluid therapy with 5–10 mL/kg per h

• Type: Ringer's lactate solution should be the preferred choice.
Symptomatic treatment and nutrition

• Analgesic (NSAIDs, Opioid. …etc.) according to degree of pain.
• NPO and Antiemetic for vomiting
• Enteral tube feeding and early oral feeding should be initiated after 48
hours.
Role of ERCP and antibiotics:

• ERCP is only indicated in patients with biliary pancreatitis and
concomitant cholangitis
• Antibiotics: only in confirmed or clinically suspected secondary
infection
Treatment of complications :
Conservative treatment:
The majority of patients with sterile (with no secondary infection) pancreatic
or peripancreatic necrosis and fluid collections as well as pancreatic
pseudocyst can be treated conservatively because most of them will resolve
spontaneously over time.
Interventional treatment:
1-Infected necrotizing pancreatitis

*Secondary infection of peripancreatic necrosis nearly always requires
invasive intervention
*Step-up treatment:
Broad-spectrum antibiotic therapy.
Percutaneous catheter drainage.
Endoscopic drainage.
Minimally invasive necrosectomy.
2- Pancreatic pseudocyst
*Indicated if pancreatic pseudocyst causes gastric outlet obstruction or
refractory pain or larger than 6 cm in diameter.
*Treatment by either Endoscopic or surgical drainage.

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Acute pancreatitis :

• Defined as Acute inflammatory process of the pancreas that range

-The major symptom

Local abdominal examination:

Criteria for diagnosis:

The diagnosis of acute pancreatitis is based on the fulfilment of two of three

(1) upper abdominal pain.

1-Pulmonary: ARDS and respiratory failure

1- The most frequent local complications associated with acute pancreatitis

Classification according to severity :

Mild: no local or systemic complications.

1-Perforated peptic ulcer

• Rate: Intravenous fluid therapy with 5–10 mL/kg per h

Symptomatic treatment and nutrition

Role of ERCP and antibiotics:

1-Infected necrotizing pancreatitis

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