Acute Pancreatitis
Definition: Acute pancreatitis is a sudden inflammation of the pancreas that can range from mild interstitial edema to severe necrotizing pancreatitis with multi-organ dysfunction. It is a reversible inflammatory process, but can be life-threatening in its severe form.
Etiology (Mnemonic: I GET SMASHED)
- I - Idiopathic
- G - Gallstones (most common cause worldwide)
- E - Ethanol (alcohol use)
- T - Trauma (especially in children)
- S - Steroids
- M - Mumps and other viral infections (e.g., Coxsackievirus)
- A - Autoimmune (e.g., autoimmune pancreatitis, SLE)
- S - Scorpion sting (rare)
- H - Hypercalcemia, Hypertriglyceridemia (>1000 mg/dL)
- E - ERCP (iatrogenic injury)
- D - Drugs (e.g., thiazides, azathioprine, valproic acid, didanosine)
Pathophysiology
Premature activation of pancreatic enzymes (especially trypsin) leads to autodigestion of pancreatic tissue, causing inflammation, tissue necrosis, and systemic inflammatory response. In severe cases, it results in capillary leak syndrome, third-spacing of fluids, and organ failure.
Clinical Features
- Acute onset of epigastric pain radiating to the back
- Nausea and vomiting
- Fever and tachycardia
- Abdominal tenderness, distension, and decreased bowel sounds
- Grey-Turner sign: Flank ecchymosis (retroperitoneal hemorrhage)
- Cullen sign: Periumbilical ecchymosis
Diagnostic Criteria (Atlanta Classification)
Diagnosis is made if 2 out of the following 3 are present:
- Characteristic abdominal pain
- Serum lipase or amylase > 3 times the upper normal limit
- Imaging (CT/MRI/USG) showing pancreatic inflammation
Investigations
- Serum lipase: Preferred over amylase (more sensitive and specific)
- Complete blood count: Leukocytosis
- Liver function tests: Elevated in gallstone pancreatitis
- Serum calcium: May be decreased (saponification)
- Triglyceride levels: Rule out hypertriglyceridemia
- Abdominal ultrasound: Evaluate for gallstones
- Contrast-enhanced CT (after 48–72 hours): To assess for necrosis, fluid collection
Severity Assessment (Revised Atlanta Classification)
- Mild: No organ failure, no local/systemic complications
- Moderate: Transient organ failure (<48 hours) or complications
- Severe: Persistent organ failure (>48 hours), high mortality
Management
Initial Stabilization:
- IV fluid resuscitation (aggressive hydration, especially in first 24 hrs)
- Pain control (IV opioids like morphine or fentanyl)
- Bowel rest (NPO initially)
- Electrolyte correction
Supportive Management:
- Enteral feeding (preferred over parenteral nutrition)
- Antibiotics not routinely indicated (used only for infected necrosis)
- Monitor for complications: necrosis, pseudocyst, ARDS, renal failure
Specific Interventions:
- Gallstone pancreatitis: ERCP if cholangitis or obstructive jaundice present
- Pancreatic necrosis: Percutaneous drainage or surgical debridement if infected
- Cholecystectomy: After resolution of acute episode to prevent recurrence
Complications
- Pancreatic pseudocyst
- Infected pancreatic necrosis
- ARDS and respiratory failure
- Hypovolemic shock
- Renal failure
- Disseminated intravascular coagulation (DIC)
Prognostic Scoring Systems
- Ranson’s Criteria (at admission and after 48 hrs)
- APACHE II Score
- BISAP Score: BUN, impaired mental status, SIRS, age >60, pleural effusion
Prevention & Patient Education
- Avoid alcohol and smoking
- Maintain a low-fat diet
- Manage hyperlipidemia and hypercalcemia
- Adhere to gallstone management recommendations
Conclusion
Acute pancreatitis is a potentially serious condition that requires early recognition and multidisciplinary management. Prompt diagnosis, supportive care, and close monitoring are key to improving patient outcomes. Understanding the etiology helps in preventing recurrences and long-term complications.
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