Acute pancreatitis is an inflammatory disease of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy due to autodigestion. Common etiologies include gallstones Gallstones Cholelithiasis (gallstones) is the presence of stones in the gallbladder. Most gallstones are cholesterol stones, while the rest are composed of bilirubin (pigment stones) and other mixed components. Patients are commonly asymptomatic but may present with biliary colic (intermittent pain in the right upper quadrant). Cholelithiasis and excessive alcohol use. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship typically present with epigastric pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, serum amylase Amylase A group of amylolytic enzymes that cleave starch, glycogen, and related alpha-1, 4-glucans. Digestion and Absorption and lipase Lipase An enzyme of the hydrolase class that catalyzes the reaction of triacylglycerol and water to yield diacylglycerol and a fatty acid anion. It is produced by glands on the tongue and by the pancreas and initiates the digestion of dietary fats. Malabsorption and Maldigestion 3 times the upper limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation of normal, or characteristic radiology findings. Ranson’s criteria is commonly used to assess the severity. Management includes aggressive intravenous (IV) hydration, analgesia Analgesia Methods of pain relief that may be used with or in place of analgesics. Anesthesiology: History and Basic Concepts, nutritional support, and treatment of the underlying cause.
Last updated: 27 Jun, 2022
Hematoxylin and eosin (H&E) stain of necrotic pancreatitis (eosinophilic area without architecture: necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage), surrounded by basophilic inflammatory cells and normal fat cells
Image: “Tryptic fat tissue necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage in severe pancreatitis” by Patho. License: CC BY-SA 3.0.Cullen’s sign, signaling blood in the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy
Image: “Cullen’s sign” by Herbert L. Fred, MD. License: CC BY 2.0.Grey-Turner’s sign due to hemorrhagic pancreatitis
Image: by Herbert L. Fred, MD and Hendrik A. van Dijk. License: CC BY 2.0.The diagnosis of acute pancreatitis requires at least 2 of the following:
Milky plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products seen in a patient with hypertriglyceridemia Hypertriglyceridemia A condition of elevated levels of triglycerides in the blood. Lipid Disorders: If seen, milky plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products should be considered as a potential cause of acute pancreatitis.
Image: “Milky plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products” by the Department of Emergency and Critical Care Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan. License: CC BY 2.0.Imaging may not be required if the 1st 2 diagnostic criteria are met MET Preoperative Care, but can be used for evaluating the underlying cause and complications:
A CT scan showing changes in the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy, which appears enlarged and edematous
Image: “A computed tomography scan” by the Department of Surgery, Helsingborg Hospital, 25187 Helsingborg, Sweden. License: CC BY 3.0.A tiny CBD CBD Atypical Parkinsonian Syndromes stone is revealed using US. Such stones should be considered a potential etiology in a patient presenting with acute pancreatitis.
Image: “F2” by the Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Road, Kaohsiung 81362, Taiwan. License: CC BY 2.0, edited by Lecturio.Acute pancreatitis on CT scan, showing edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema around the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy
Image: “Arterial phase contrast CT showing an acute pancreatitis” by Benoît Bédat et al AL Amyloidosis. License: CC BY 4.0.Identifying the severity of acute pancreatitis is helpful in order to ensure the patient is treated appropriately:
Present on admission | At 48 hours after admission |
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Age > 55 years | Decrease in hematocrit Hematocrit The volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value. Neonatal Polycythemia > 10% |
WBC > 16,000/μL | Increase in BUN by ≥ 5 mg/dL |
Blood glucose Glucose A primary source of energy for living organisms. It is naturally occurring and is found in fruits and other parts of plants in its free state. It is used therapeutically in fluid and nutrient replacement. Lactose Intolerance > 200 mg/dL | Serum Ca CA Condylomata acuminata are a clinical manifestation of genital HPV infection. Condylomata acuminata are described as raised, pearly, flesh-colored, papular, cauliflower-like lesions seen in the anogenital region that may cause itching, pain, or bleeding. Condylomata Acuminata (Genital Warts) < 8 mg/dL |
Serum LDH LDH Osteosarcoma > 350 IU/L | PaO2 < 60 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma Hg |
Aspartate Aspartate One of the non-essential amino acids commonly occurring in the l-form. It is found in animals and plants, especially in sugar cane and sugar beets. It may be a neurotransmitter. Synthesis of Nonessential Amino Acids transaminase Transaminase A subclass of enzymes of the transferase class that catalyze the transfer of an amino group from a donor (generally an amino acid) to an acceptor (generally a 2-keto acid). Most of these enzymes are pyridoxyl phosphate proteins. Catabolism of Amino Acids ( AST AST Enzymes of the transferase class that catalyze the conversion of l-aspartate and 2-ketoglutarate to oxaloacetate and l-glutamate. Liver Function Tests) > 250 IU/L | Base deficit > 4 mEq/L |
Estimated fluid sequestration > 6 L |
BUN | > 25 mg/dL |
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Impaired mental status | GCS GCS A scale that assesses the response to stimuli in patients with craniocerebral injuries. The parameters are eye opening, motor response, and verbal response. Coma < 15 |
Systemic inflammatory response syndrome Systemic Inflammatory Response Syndrome Sepsis in Children (SIRS) | Evidence of SIRS |
Age | > 60 years |
Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion | Positive finding on imaging |
Abdominal CT scan showing the initial area of patchy necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage around the head of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy
Image: “Abdominal CT scan” by Francesco Fontana. License: CC BY 4.0.CT scans in a patient who developed infected pancreatic
necrosis
Necrosis
The death of cells in an organ or tissue due to disease, injury or failure of the blood supply.
Ischemic Cell Damage.
A: Extensive pancreatic
necrosis
Necrosis
The death of cells in an organ or tissue due to disease, injury or failure of the blood supply.
Ischemic Cell Damage with a large amount of gas is seen in the body and tail of the
pancreas
Pancreas
The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue.
Pancreas: Anatomy.
B: After 60 days of follow-up, a small decrease in the collection of gas is noted.
C: Four months after hospital discharge:
atrophy
Atrophy
Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes.
Cellular Adaptation of pancreatic parenchyma.
Acute pancreatitis repeatedly occurred 1 month after the 1st operation, and a pancreatic pseudocyst Pancreatic pseudocyst Cyst-like space not lined by epithelium and contained within the pancreas. Pancreatic pseudocysts account for most of the cystic collections in the pancreas and are often associated with chronic pancreatitis. Acute Cholangitis developed at the same site. Enhanced CT showed a cyst with a diameter of 29 mm MM Multiple myeloma (MM) is a malignant condition of plasma cells (activated B lymphocytes) primarily seen in the elderly. Monoclonal proliferation of plasma cells results in cytokine-driven osteoclastic activity and excessive secretion of IgG antibodies. Multiple Myeloma in the body of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: Anatomy.
Image: “ Pancreatic pseudocyst Pancreatic pseudocyst Cyst-like space not lined by epithelium and contained within the pancreas. Pancreatic pseudocysts account for most of the cystic collections in the pancreas and are often associated with chronic pancreatitis. Acute Cholangitis” by the Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, 1-1-1 Honjo, Kumamoto, 860-8556 Japan. License: CC BY 4.0.CT scan of the abdomen with IV contrast showing a contrast-enhanced mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast (solid arrow) at the splenic artery (branching from the superior mesenteric artery Superior mesenteric artery A large vessel supplying the whole length of the small intestine except the superior part of the duodenum. It also supplies the cecum and the ascending part of the colon and about half the transverse part of the colon. It arises from the anterior surface of the aorta below the celiac artery at the level of the first lumbar vertebra. Small Intestine: Anatomy) compatible with a splenic artery pseudoaneurysm Pseudoaneurysm Not an aneurysm but a well-defined collection of blood and connective tissue outside the wall of a blood vessel or the heart. It is the containment of a ruptured blood vessel or heart, such as sealing a rupture of the left ventricle. False aneurysm is formed by organized thrombus and hematoma in surrounding tissue. Thoracic Aortic Aneurysms. Hemoretroperitoneum and hemoperitoneum were demonstrated (hollow arrows).
Image: “CT scan of the abdomen” by the Accident and Emergency Department, Ruttonjee Hospital, Wanchai, Hong Kong. License: CC BY 4.0.Contrast-enhanced CT scan of the abdomen reveals a 5 × 6 × 7 cm complex cystic Cystic Fibrocystic Change mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast in the region of the uncinate process of the pancreatic head with an enhancing capsule Capsule An envelope of loose gel surrounding a bacterial cell which is associated with the virulence of pathogenic bacteria. Some capsules have a well-defined border, whereas others form a slime layer that trails off into the medium. Most capsules consist of relatively simple polysaccharides but there are some bacteria whose capsules are made of polypeptides. Bacteroides and a small hyperdensity consistent with pseudoaneurysm Pseudoaneurysm Not an aneurysm but a well-defined collection of blood and connective tissue outside the wall of a blood vessel or the heart. It is the containment of a ruptured blood vessel or heart, such as sealing a rupture of the left ventricle. False aneurysm is formed by organized thrombus and hematoma in surrounding tissue. Thoracic Aortic Aneurysms of a peripancreatic vessel with active bleeding into the pancreatic pseudocyst Pancreatic pseudocyst Cyst-like space not lined by epithelium and contained within the pancreas. Pancreatic pseudocysts account for most of the cystic collections in the pancreas and are often associated with chronic pancreatitis. Acute Cholangitis.
Image: “Contrast-enhanced CT scan” by Rohan Mandaliya. License: CC BY 2.0.