Acute Pancreatitis

A 48 year old female presents with sudden severe epigastric pain radiating to the back associated with nausea and vomiting. Pain worsens after meals and improves on leaning forward. She has a history of gallstones and recurrent right upper quadrant pain after fatty meals. On examination, she is tachycardic with epigastric tenderness and decreased bowel sounds. Laboratory investigations show markedly elevated serum lipase and amylase with mild elevation of liver enzymes. Ultrasound demonstrates gallstones, and CT abdomen shows pancreatic inflammation. Diagnosis?

Diagnosis is acute gallstone pancreatitis.

1. Definition

Acute pancreatitis is an acute inflammatory process of the pancreas characterized by abdominal pain and elevated pancreatic enzymes due to autodigestion by activated pancreatic enzymes.

2. Etiology

2.1 Common Causes

1. Gallstones
2. Alcohol abuse

2.2 Other Causes

1. Hypertriglyceridemia
2. Hypercalcemia
3. Post-ERCP pancreatitis
4. Trauma
5. Drugs
• Azathioprine
• Valproate
• Thiazides
• Didanosine
6. Infections
• Mumps
• Coxsackie virus
7. Autoimmune pancreatitis
8. Pancreatic tumors
9. Scorpion sting

2.3 Mnemonic: GET SMASHED

• Gallstones
• Ethanol
• Trauma
• Steroids
• Mumps
• Autoimmune
• Scorpion sting
• Hypertriglyceridemia/Hypercalcemia
• ERCP
• Drugs

3. Pathophysiology

1. Premature activation of trypsinogen to trypsin within the pancreas
2. Autodigestion of pancreatic tissue by activated enzymes
3. Pancreatic inflammation and edema
4. Release of inflammatory cytokines causing systemic inflammatory response
5. Severe disease may progress to pancreatic necrosis, multiorgan failure, and shock

4. Classification

4.1 Revised Atlanta Classification

Interstitial Edematous Pancreatitis

• Most common form
• Diffuse pancreatic inflammation without necrosis

Necrotizing Pancreatitis

• Pancreatic or peripancreatic tissue necrosis
• Associated with severe disease and higher mortality

5. Clinical Features

5.1 Core Features

1. Severe epigastric pain radiating to the back
2. Nausea and vomiting
3. Pain relieved by leaning forward
4. Fever
5. Tachycardia
6. Epigastric tenderness
7. Decreased bowel sounds

5.2 Severe Disease Features

1. Hypotension
2. Shock
3. Respiratory distress
4. Altered mental status
5. Oliguria

5.3 Physical Signs

1. Cullen sign: periumbilical ecchymosis
2. Grey Turner sign: flank ecchymosis
3. Abdominal distension

6. Diagnosis

Diagnosis requires at least 2 of the following 3 criteria:

1. Characteristic abdominal pain
2. Serum lipase or amylase ≥3 times upper limit of normal
3. Imaging findings consistent with pancreatitis

7. Laboratory Findings

1. Elevated serum lipase (more specific and preferred)
2. Elevated serum amylase
3. Leukocytosis
4. Elevated CRP
5. Elevated AST/ALT in gallstone pancreatitis
6. Hypocalcemia in severe disease
7. Hyperglycemia

8. Imaging

8.1 Ultrasound Abdomen

1. First-line imaging in suspected gallstone pancreatitis
2. Detects gallstones and biliary obstruction

8.2 Contrast-Enhanced CT Abdomen

1. Demonstrates pancreatic inflammation and necrosis
2. Detects complications such as fluid collections or abscesses
3. Used when diagnosis is uncertain or severe disease is suspected
4. Best performed after 48–72 hours if assessing necrosis

9. Severity Assessment

9.1 BISAP Score

1. BUN elevation
2. Impaired mental status
3. SIRS
4. Age >60 years
5. Pleural effusion

9.2 Ranson Criteria

Used to assess severity and mortality risk.

9.3 Severity Categories

Mild Acute Pancreatitis

• No organ failure or complications

Moderately Severe Acute Pancreatitis

• Transient organ failure or local complications

Severe Acute Pancreatitis

• Persistent organ failure (>48 hours)

10. Complications

10.1 Local Complications

1. Acute peripancreatic fluid collections
2. Pancreatic pseudocyst
3. Pancreatic necrosis
4. Abscess formation
5. Hemorrhage

10.2 Systemic Complications

1. Shock
2. Acute respiratory distress syndrome (ARDS)
3. Acute kidney injury
4. Disseminated intravascular coagulation (DIC)
5. Sepsis
6. Multiorgan failure

11. Management

11.1 Initial Management

1. Early goal-directed IV fluid resuscitation (Lactated Ringer’s preferred)
2. Adequate pain control
3. Early oral or enteral feeding as tolerated
4. Oxygen and supportive care
5. Monitor urine output and organ function

11.2 Etiology-Specific Treatment

1. ERCP for gallstone pancreatitis with cholangitis or persistent biliary obstruction
2. Cholecystectomy after recovery in gallstone pancreatitis
3. Alcohol cessation counseling
4. Treat hypertriglyceridemia if present

11.3 Antibiotics

1. Prophylactic antibiotics are not routinely recommended
2. Antibiotics indicated only for infected pancreatic necrosis or confirmed infection

12. Key Clinical Insight

Severe epigastric pain radiating to the back with elevated serum lipase strongly suggests acute pancreatitis, especially in patients with gallstones or alcohol use

13. Key Exam Points

1. Gallstones and alcohol are the most common causes
2. Lipase is more specific than amylase
3. Pain improves by leaning forward
4. Ultrasound is first-line for gallstones
5. CT scan evaluates necrosis and complications
6. Early enteral feeding is preferred over prolonged NPO
7. Pancreatic pseudocyst is a classic late complication
8. ARDS is an important cause of mortality in severe pancreatitis
9. Infected necrosis requires antibiotics ± drainage
10. Severe pancreatitis can lead to multiorgan failure