Acute Pancreatitis

Some important definitions

   Diagnosis of Acute Pancreatitis:

¤Two of the following three features

  1. Characteristic Abdominal pain


2. Serum lipase(or amylase) activity 3 times normal

3.Characteristic findings on CECT (MRI  or US)

¤If (1) and (2) are present, CT is not required for diagnosis in in ER or admission


Definition of types of Acute Pancreatitis

 Atlanta 92

– Interstitial Pancreatitis

-Sterile Necrotizing Pancreatitis

-Infected Necrotizing Pancreatitis

♦Revised Atlanta 2012

– Interstitial edematous Pancreatitis

-Necrotizing Pancreatitis

  • Both types are either sterile or infected

Interstitial edematous Pancreatitis:

♦ Diffuse or focal enlargement

-inflammatory edema

♦ Resolves in the first week

Necrotizing Pancreatitis:

♦ Necrosis of pancreatic parenchyma,peripancreatic tissue or both

◊ impairment of pancreatic perfusion

– Evolves for several days

-Early CECT may underestimate extent of disease

Pancreatic necrosis:

  • – Focal/diffuse nonviable pancreatic parenchyma
  • – Accompanied by peripancreatic fat necrosis
  • -Necrosis can be sterile/infected
  • -There is no absolute correlation between extent of necrosis and risk of infection
  • -Infected necrosis is rare during the first week

Course and pathophysiology of Acute Pancreatitis

  •     Two overlapping phases
  • ♦ Early Phase: first week
  • -SIRS and organ failure is characteristic.
  • – Local complications usually not present: Extent of morphological changes is not proportionate to the severity of organ failure
  • – No need to evaluate morphological changes in early phase (in 72 hour)
  • ♦ Late phase: after the first week
  • -Severity related to persistent organ failure and local complications
  • – Local complications:Need for morphological evaluation

                  Definitions of Local Complications

Pancreatic and Peripancreatic collections:

-♦ Collections composed of fluid alone

•Acute peripancreatic Fluid Collections (APFC)- first 4 weeks

• Pancreatic pseudocyst(after 4 weeks)

-♦ Collections in part with solid components

• Acute necrotic collections- first 4 weeks

• Walled-off necrosis (WON)- after 4 weeks


– Acute fluid collection occur in 30-50% of acute pancreatitis

-On CT: Low attenuation mass with poor margin and no capsule

– Most resolves spontaneously

-Suspected if:

1.Recurrence of abdominal pain

2.Secondary increase in serum amylase level

3.Increased organ dysfunction or sepsis: increase in CRP,fever,leucocytosis


Grades of severity of Acute Pancreatitis:

1.Mild AP:

– No organ failure

– No Local/systemic complications

2. Moderately severe AP:

– Transient organ failure (resolves >48 hours) and/or

-Local or systemic complications without persistent organ failure

3. Severe AP:

-Persistent organ failure(>48 hours): single or multiple


Peripancreatic necrosis:

  • – Necrotic fatty tissue debris around the pancreas
  • – Not appreciated on imaging, so important for surgeons


  • – Fluid collection that persists for 4-6 weeks and becomes encapsulated by a fibrous wall or granulation tissue
  • – Located adjacent to or body of the pancreas

Walled-off necrosis:

  • – Walled-off fluid appearing pseudocyst-like structure involving the pancreas
  • – Should be drained after 5-6 weeks later
  • Previously termed Organized pancreatic necrosis.

Pancreatic abscess:

  • – Circumscribed intra-abdominal collection of pus occurring after an episode of pancreatitis or pancreatic trauma
  • – It is not infected necrosis

Hemorrhagic pancreatitis:

  • – Not synonymous for necrotizing pancreatitis
  • – Hemorrhage is more commonly associated with pseudoaneurysm formation, erosion of peripancreatic blood vessels

Ranson Criteria:

  • – Uses 11 signs
  • – Disease is mild if score <2
  • – Disease is severe if score >
  • Drawback of Ranson’s criteria:
  • – List is cumbersome
  • – Takes 48 hours to complete
  • – Not validated beyond 48 hours


Glasgow criteria:

  • – Slightly simplified list is used
  • – Uses 8 criteria
  • – Similar drawback as Ranson’s criteria


  • – Uses 12 variables of the patient
  • – Most patients survive if APACHEII score ≤9 during the first 48 hours
  • – APACHE score ³13 are more likely to die

BISAP Score (Bed Side Index in Acute Pancreatitis):

  • – B- BUN>25 mg/dl
  • – I- Impaired mental status
  • – S-SIRS
  • – A-Age >60 years
  • – P- Pleural effusion
  • – BISAP 4 or 5 is associated with 7-12 fold increased risk of developing organ failure
  •  SIRS: 2 or more of the following criteria if present
  •                         • Pulse: >90 beats/min
  •                         Respiratory rate: >20/min
  •                         Temp: <36°c or >38°c
  •                         WBC: <4,000/mm³ or >12,000/mm³


Diagnostic laboratory parameters:


Rises within few hours after the symptom onset

– Returns to normal within 3-5 days

– S. Amylase may be in alcohol and triglyceride induced AP

Causes of raised amylase in the absence of AP

  • – Macro-amylasemia: Syndrome characterized by formation of large molecular complex between amylase and abnormal immunoglobulin
  • – ↓GFR
  • – Disease of salivary gland
  • – Extrapancreatic abdominal inflammatory disease
  •                                     • Acute appendicitis
  •                                     • Cholecystitis
  •                                     • Intestinal obstruction
  •                                     •Intestinal ischemia
  •                                     •PUD
  •                                     •Gynecological disease



Walled-off Pancreatic Necrosis (WON)

Pancreatic Necrosis

  • – Nonviable pancreas
  • – Usually associated with peri-pancreatic fat necrosis
  • – Frequently associated with major pancreatic duct disruption
  • – Over the course of several weeks
  • – Area of necrosis continue to evolve and expand
  • – Contain both liquid and solid


Indications for drainage of sterile WON

  • – Refractory abdominal pain
  • – Gastric outlet obstruction
  • – Failure to thrive at 4 or more weeks after the onset of AP

*Endoscopic drainage of pancreatic necrosis is technically difficult than drainage of pseudocyst


Alternative management of pancreatic necrosis

  • – Nutritional support with parenteral/ enteral (jejunal feeding)
  • Non endoscopic drainage
  •                 • Percutaneous drainage
  •                 • Surgical drainage
  •                 • Minimally invasive surgical drainage
  • – Because of the need to evacuate solid material,the endoscopic approach to drain WON differs from pseudocyst drainage
  • – Endoscopic endoscopic transmural drainage is prefereable to endoscopic transpapillary draingae as transpapillary route is not adequate for drainage of solid debris.


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