DIAGNOSIS OF ACUTE

PANCREATITIS
DIAGNOSIS AND CLASSIFICATION

• Accurate diagnosis – atleast 2 of the following

three diagnostic features
1. Abdominal pain consistent with acute
pancreatitis
2. Serum lipase or amylase levels – 3 times the
upper limit
3. Findings of acute pancreatitis on cross-
sectional imaging(CT/MRI)
CLASSIFICATION SYSTEMS
• Systemic complications include:
• Failure of an organ system(respiratory, Cardiovasc., or
renal)
• Exacerbation of a pre-existing disorder(COPD, heart
failure or chr. liver ds.)

• Local complications include:

• Peripancreatic fluid collections
• Pseudocysts
• Pancreatic or peripancreatic necrosis (sterile/infected)
• Persistent organ failure(Severe Acute Pancreatitis) -
30% mortality
• Critical Pancreatitis – associated with the highest
mortality
 PREDICTION OF SEVERITY
• Clinical factors – increase risk
of complications or death:
1. Age > 60 years of age
2. Comorbid illnesses(cancer, heart failure,
and chronic kidney and liver disease),
3. H/o chronic alcohol consumption
4. Obesity (body mass index 30 kg/m2
5. Long term, heavy alcohol use
 Laboratory measures
• Measure of intravascular volume depletion:
• Elevated hematocrit
• Elevated BUN and creatinine
• Markers of inflammation:
• C-reactive protein
• IL- 6, 8, 10

• Degree of elevation of amylase or lipase level – no

prognostic value
• CT study – Early CT study underestimates the severity
of the disease
 Scoring systems
• APACHE-II,
• APACHE-O(combined with scoring for
obesity),
• the Glasgow scoring system,
• HAPS,
• PANC 3,
• the Japanese Severity Score,
• Pancreatitis Outcome Prediction and
• BISAP score
• Scoring systems overestimate the severity of
disease
• Clinical evaluation – better
• Systemic Inflammatory Response
Syndrome(SIRS) : ≥ 2/4
• Temp< 360C or >380 C
• Pulse ≥ 90/min
• WBC <4000 or >12000/mm3
• Respiratory Rate > 20/min
• SIRS persisting for ≥ 48 hrs –
poor prognosis
TO IDENTIFY PATIENTS AT RISK
• Demographic and clinical factors at admission:
1. Age> 60yrs
2. BMI > 30
3. Coexisting conditions
• Lab values at admission and during the next 24-
48 hrs:
1. Hct > 44%
2. BUN > 20mg/dl
3. S. Creat > 1.8mg/dl
• Presence of SIRS
INDICATIONS FOR INTENSIVE CARE
• Patients with signs of respiratory
failure or hypotension that fail to
respond to initial resuscitation
• Patients with multiorgan
dysfunction
• Patients with persistent SIRS,
increased levels of BUN or creatinine,
increased hematocrit, or underlying
cardiac or pulmonary illness
 INDICATIONS FOR TRANSFER
• Patients who do not respond to initial
resuscitation, with persistent organ
failure or extensive local
complications, should be considered
for transfer to a comprehensive
pancreatitis center with
multidisciplinary expertise that
includes therapeutic endoscopy,
interventional radiology, and surgery.
MANAGEMENT OF ACUTE
PANCREATITIS
 FLUID RESUSCITATION
• Aggressive fluid administration during first
24 hours – reduces morbidity and mortality

• Administration of a crystalloid solution:

• 5-10ml/kg/hr about 2500-4000 ml within
first 24hrs
• Patients undergoing volume resuscitation
should have the head of the bed elevated,
undergo continuous pulse oximetry, and
receive supplemental oxygen
• Clinical cardiopulmonary monitoring for fluid
status, hourly measurement of urine output and
monitoring of BUN and Hct
• Excessive fluid administration – risk of
abdominal compartment syndrome, sepsis,
need for intubation and death
 FEEDING
• Total Parenteral Nutrition – Expensive, riskier
and no more effective than enteral nutrition
• Mild acute pancreatitis – No need for complete
resolution of pain or normalisation of enzymes
before oral feeding is started
• Start on a low fat diet in the absence of severe
pain, nausea, vomiting and ileus.
• Artificial enteral feeding – if symptoms
continue to be severe or intolerant to oral feeds
• Nasojejunal feeding – best for
minimising pancreatic secretion
• Nasogastic or nasoduodenal feeding
clinically equivalent
• TPN – reserved for cases in which enteral
nutrition is not tolerated or nutritional goals
are not met
• Oral feeding – attempted with an interval of
3- 5 days before tube feeding is considered
 ANTIBIOTICS AND ERCP
• Prophylaxis with antibiotic therapy - not
recommended for type of acute pancreatitis unless
infection is suspected or confirmed
• ERCP- indicated in pts with E/O cholangitis superimposed
on gallstone pancreatitis and in patients with
documented choledocholithiasis
• MRCP - identifying retained common bile duct stones - for
patients with suspected gallstone pancreatitis.
• MRI - helpful in distinguishing walled-off necrosis
from a pseudocyst
• Endoscopic ultrasonography is a highly sensitive test for
detecting cholelithiasis and choledocholithiasis - an
alternative to MRCP, which has limited accuracy for
detecting smaller gallstones or sludge.
 TREATMENT OF FLUID COLLECTIONS AND
NECROSIS
• Acute peripancreatic fluid collections – no therapy

• Symptomatic pseudocysts – use of endoscopic techniques

• Necrotising pancreatitis:
- Sterile : no treatment
- Infected(H/o fever, leukocytosis, increasing abd pain and air
bubbles in the necrotic cavity on CT scan): Broad spectrum
antibiotics
• Delay of invasive intervention for atleast 4 weeks for
walling off of the necrotic collection – makes debridement
easier and reduces the complications
• Unstable patients – Initial placement of a percutaneous
drain in the collection to reduce sepsis and allow the
4- week delay
 LONG TERM CONSEQUENCES
• Pancreatic exocrine and
endocrine dysfunction(20-30%)

• Chronic pancreatitis(33-50%)
• Risk factors for transition to recurrent attacks
and chronic pancreatitis:
- Severity of initial attack, degree of pancreatic
necrosis, cause of acute pancreatitis
- Heavy alcohol with smoking as
cofactor dramatically increases the
risk
 PREVENTION OF RELAPSE

• Cholecystectomy – prevents recurrent

gall stone pancreatitis(should be
performed during the initial hospital stay
for mild pancreatitis – reduce the risk of
relapse)
• Abstinence markedly lowrs the risk
of recurrence
• Smoking cessation
• Tight control of hyperlipidemia
THANK YOU