Acute pancreatitis
Classification & external resources

Pancreas
ICD-10	K85.
ICD-9	577.0
DiseasesDB	9539
MedlinePlus	000287
eMedicine	med/1720  radio/521

Acute pancreatitis is rapidly-onset inflammation of the pancreas. Depending on its severity, it can have severe complications and high mortality despite treatment. While mild cases are often successfully treated with conservative measures or laparoscopy, severe cases require invasive surgery (often more than one intervention) to contain the disease process. Image File history File links Illu_pancrease. ... The pancreas is an organ in the digestive and endocrine system (of vertebrates[2]). It is both exocrine (secreting pancreatic juice containing digestive enzymes) and endocrine (producing several important hormones, including insulin, glucagon, and somatostatin). ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... // K00-K93 - Diseases of the digestive system (K00-K14) Diseases of oral cavity, salivary glands and jaws (K00) Disorders of tooth development and eruption (K01) Embedded and impacted teeth (K02) Dental caries (K03) Other diseases of hard tissues of teeth (K04) Diseases of pulp and periapical tissues (K040) Pulpitis (K05... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Pancreatitis is inflammation of the pancreas. ... An abscess on the skin, showing the redness and swelling characteristic of inflammation. ... The pancreas is an organ in the digestive and endocrine system (of vertebrates[2]). It is both exocrine (secreting pancreatic juice containing digestive enzymes) and endocrine (producing several important hormones, including insulin, glucagon, and somatostatin). ... Laparoscopic surgery, also called keyhole surgery (when natural body openings are not used), bandaid surgery, or minimally invasive surgery (MIS), is a surgical technique. ... open surgery ...

Symptoms and signs

• Severe upper left abdominal pain
• Nausea, vomiting, diarrhea and loss of appetite.
• Fever
• Shock, hemodynamic instability

Common Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. ... For the Beck song, see Nausea (song). ... Vomiting (also throwing up or emesis) is the forceful expulsion of the contents of ones stomach through the mouth and sometimes the nose. ... Types 5-7 on the Bristol Stool Chart are often associated with diarrhea Diarrhea (in American English) or diarrhoea (in British English) is a generally unpleasant condition in which the sufferer has frequent watery, loose bowel movements (from the ancient Greek word διαρροή = leakage; literally meaning to run through). Acute infectious... Anorexia (deriving from the Greek όρεξη (orexe) = appetite) is the decreased sensation of appetite. ... An analogue medical thermometer showing the temperature of 38. ... This article is about the medical condition. ...

• Grey Turner sign (hemorrhagic discoloration of the flanks), Cullen sign (hemorrhagic discoloration of the umbilicus)

 pancreatic pseudocyst, pancreatic dysfunction (malabsorption due to exocrine failure) or diabetes mellitus. 

Grey-Turners sign refers to bruising of the flanks. ... Cullens sign is blue-black bruising of the area around the umbilicus. ... A pancreatic pseudocyst is a circumscribed collection of pancreatic fluid typically located in the lesser omentum. ... Wikipedia does not have an article with this exact name. ... Malabsorption is the state of impaired absorption of nutrients in the small intestine. ... For the disease characterized by excretion of large amounts of very dilute urine, see diabetes insipidus. ...

Causes

Most common causes

A common mnemonic for the causes of pancreatitis spells "I get smashed", an allusion to heavy drinking (one of the many causes): Wikiquote has a collection of quotations related to: English mnemonics A mnemonic (pronounced in Received Pronunciation) is a memory aid, and most serve an educational purpose. ...

• I - idiopathic
• G - gallstone. Gallstones that travel down the common bile duct and which subsequently get stuck in the Ampulla of Vater can cause obstruction in the outflow of pancreatic juices from the pancreas into the duodenum. The backflow of these digestive juices causes lysis (dissolving) of pancreatic cells and subsequent pancreatitis.
• E - ethanol (alcohol)
• T - trauma
• S - steroids
• M - mumps (paramyxovirus) and other viruses (Epstein-Barr virus, Cytomegalovirus)
• A - autoimmune disease (Polyarteritis nodosa, Systemic lupus erythematosus)
• S - scorpion sting - Tityus Trinitatis - Trinidad/ snake bite
• H - hypercalcemia, hyperlipidemia/hypertriglyceridemia and hypothermia
• E - ERCP (Endoscopic Retrograde Cholangio-Pancreatography - a procedure that combines endoscopy and fluoroscopy)
• D - drugs (SAND - steroids & sulfonamides, azathioprine, NSAIDS, diuretics such as furosemide and thiazides, & didanosine) and duodenal ulcers

Idiopathic means arising spontaneously or from an obscure or unknown cause. ... This article or section does not adequately cite its references or sources. ... X-Ray of the bile duct during a laprascopic cholecystectomy A bile duct is any of a number of long tube-like structures that carry bile. ... The Ampulla of Vater is the part of the duodenum where the common bile duct empties into the second part of the duodenum, so named because it has the appearance of an ampulla. ... In anatomy of the digestive system, the duodenum is a hollow jointed tube connecting the stomach to the jejunum. ... Ethanol, also known as ethyl alcohol, drinking alcohol or grain alcohol, is a flammable, colorless, slightly toxic chemical compound with a distinctive perfume-like odor, and is the alcohol found in alcoholic beverages. ... Bottles of cachaça, a Brazilian alcoholic beverage. ... In medicine, a trauma patient has suffered serious and life-threatening physical injury resulting in secondary complications such as shock, respiratory failure and death. ... In chemistry and biology, Steroids are a type of lipid, characterized by a carbon skeleton with four fused rings. ... Genera See text Paramyxoviruses are viruses of the Paramyxoviridae family of the Mononegavirales order; they are negative-sense single-stranded RNA viruses responsible for a number of human and animal diseases. ... The Epstein-Barr virus (EBV), also called Human herpesvirus 4 (HHV-4), is a virus of the herpes family (which includes Herpes simplex virus and Cytomegalovirus), and is one of the most common viruses in humans. ... species see text Cytomegalovirus (CMV), is a genus of Herpes viruses; in humans the species is known as Human herpesvirus 5 (HHV-5). ... Autoimmune diseases arise from an overactive immune response of the body against substances and tissues normally present in the body. ... Polyarteritis nodosa (or periarteritis nodosa) is a serious blood vessel disease. ... Superfamilies Pseudochactoidea Buthoidea Chaeriloidea Chactoidea Iuroidea Scorpionoidea See classification for families. ... A snakebite, or snake bite, is a bite inflicted by a snake. ... Hypercalcaemia is an elevated calcium level in the blood. ... Hypercholesterolemia (literally: high blood cholesterol) is the presence of high levels of cholesterol in the blood. ... In medicine, hypertriglyceridemia (or Hypertriglyceridaemia) denotes high (hyper-) blood levels (-emia) of triglycerides, the most abundant fatty molecule in most organisms. ... Hypothermia refers to any condition in which the temperature of a body drops below the level required for normal metabolism and/or bodily function to take place. ... Endoscopic retrograde cholangiopancreatography (ERCP) is endoscopy of the biliary tree and the pancreatic duct. ... Endoscopic images of a duodenal ulcer Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ... A modern fluoroscope. ... Oral medication A medication is any drug taken to cure or reduce the symptoms of an illness or ongoing medical condition. ... In chemistry and biology, Steroids are a type of lipid, characterized by a carbon skeleton with four fused rings. ... Sulfonamides, also known as sulfa drugs, are synthetic antimicrobial agents derived from sulfonic acid. ... Azathioprine is a chemotherapy drug, now rarely used for chemotherapy but more for immunosuppression in organ transplantation, autoimmune disease such as rheumatoid arthritis or inflammatory bowel disease such as Crohns disease. ... Wikipedia does not yet have an article with this exact name. ... A diuretic is any drug that tends to increase the flow of urine from the body (diuresis). ... Furosemide (INN) or frusemide (former BAN) is a loop diuretic used in the treatment of congestive heart failure and edema. ... Wikipedia does not yet have an article with this exact name. ... Didanosine (2-3-dideoxyinosine, ddI) is sold under the trade names Videx® and Videx EC®. It is a reverse transcriptase inhibitor, effective against HIV and usually used in combination with other antiviral drug therapy as part of highly active antiretroviral therapy (HAART). ...

Less common causes

• pancreas divisum
• long common duct
• carcinoma of the head of pancreas, and other cancer
• ascaris blocking pancreatic outflow
• ischemia from bypass surgery
• fatty necrosis
• pregnancy
• infections other than mumps, including varicella zoster
• repeated marathon running.
• cystic fibrosis

Pancreas divisum is a congenital defect in which parts of the pancreas to fail to fuse together. ... Common duct can refer to: Common hepatic duct Common bile duct Category: ... In medicine, carcinoma apanting dog named rufis It is malignant by definition: carcinomas invade surrounding tissues and organs, and may spread to lymph nodes and distal sites (metastasis). ... The head of pancreas is flattened from before backward, and is lodged within the curve of the duodenum. ... Cancer is a class of diseases or disorders characterized by uncontrolled division of cells and the ability of these to spread, either by direct growth into adjacent tissue through invasion, or by implantation into distant sites by metastasis (where cancer cells are transported through the bloodstream or lymphatic system). ... Species Ascaris lumbricoides Ascaris suum Ascaris is a genus of parasitic nematodes. ... In medicine, ischemia (Greek ισχαιμία, isch- is restriction, hema or haema is blood) is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. ... Coronary artery bypass surgery Roux-en-Y gastric bypass surgery This is a disambiguation page — a navigational aid which lists other pages that might otherwise share the same title. ... Necrosis (in Greek Νεκρός = Dead) is the name given to unprogrammed death of cells and living tissue. ... A pregnant woman near the end of her term Pregnancy is the carrying of one or more embryos or fetuses by female mammals, including humans, inside their bodies. ... An infection is the detrimental colonization of a host organism by a foreign species. ... The varicella-zoster virus (VZV), also known as human herpesvirus 3 (HHV-3), is one of the eight herpesviruses known to affect humans (and other vertebrates). ... Modern day marathon runners The word marathon refers to a long-distance road running event of 42. ...

Causes by demographic

The most common causes of pancreatitis, are as follows :

• Western countries - chronic alcoholism and gallstones accounting for more than 85% of all cases
• Eastern countries - gallstones
• Children - trauma
• Adolescents and young adults - mumps

Pathogenesis

The exocrine pancreas produces a variety of enzymes, such as proteases, lipases and saccharidases. These enzymes contribute to food digestion by breaking down food tissues. In acute pancreatitis, the worst offender among these enzymes may well be the protease trypsinogen which converts to the active trypsin which is most responsible for auto-digestion of the pancreas which causes the pain and complications of pancreatitis. Exocrine gland refers to glands that secrete their products via a duct. ... Ribbon diagram of the enzyme TIM, surrounded by the space-filling model of the protein. ... Proteases (proteinases, peptidases, or proteolytic enzymes) are enzymes that break peptide bonds between amino acids of proteins. ... A lipase is a water-soluble enzyme that catalyzes the hydrolysis of ester bonds in water–insoluble, lipid substrates. ... For the band, see Saliva (band). ... This article or section does not adequately cite its references or sources. ... Trypsinogen (EC 3. ... Trypsin (EC 3. ...

Histopathology The acute pancreatitis (acute hemorrhagic pancreatic necrosis) is characterized by acute inflammation and necrosis of pancreas parenchyma, focal enzymic necrosis of pancreatic fat and vessels necrosis - hemorrhage. These are produced by intrapancreatic activation of pancreatic enzymes. Lipase activation produces the necrosis of fat tissue in pancreatic interstitium and peripancreatic spaces. Necrotic fat cells appear as shadows, contours of cells, lacking the nucleus, pink, finely granular cytoplasm. It is possible to find calcium precipitates (hematoxylinophilic). Digestion of vascular walls results in thrombosis and hemorrhage. Inflammatory infiltrate is rich in neutrophils. Photos at: Atlas of Pathology Neutrophil granulocytes (commonly referred to as neutrophils) are a class of white blood cells and are part of the immune system. ...

Investigations

• Blood Investigations - Full blood count, Renal function tests, Liver Function, serum calcium, serum amylase and lipase, Arterial blood gas
• Imaging - Chest Xray (for exclusion of perforated viscus), Abdominal Xrays (for detection of "sentinel loop" dilated duodenum sign, and gallstones which are radioopaque in 10%) and CT abdomen

A full blood count (FBC) or complete blood count (CBC) is a test requested by a doctor or other medical professional that gives information about the cells in a patients blood. ... It has been suggested that Renal anomalies and Renal plasma threshold be merged into this article or section. ... Arterial blood gas measurement is a blood test that is performed to determine the concentration of oxygen, carbon dioxide and bicarbonate, as well as the pH, in the blood. ...

Amylase and lipase

• Serum amylase rises 2 to 12 hours from the onset of symptoms, and normalises within 1 week
• Serum lipase rises 4 to 8 hours from the onset of symptoms and normalises within 8 to 14 days.
• Serum amylase may be normal (in 10% of cases) for cases of acute on chronic pancreatitis (depleted acinar cell mass) and hypertriglyceridemia
• Reasons for false positive elevated serum amylase include salivary gland disease (elevated salivary amylase) and macroamylasemia
• If Lipase level is about 2.5 to 3 times that of Amylase, it is an indication of pancreatitis due to Alcohol ^[1].

Regarding selection of these tests, two practice guidelines state: Amylase is the name given to glycoside hydrolase enzymes that break down starch. ... A lipase is a water-soluble enzyme that catalyzes the hydrolysis of ester bonds in water–insoluble, lipid substrates. ...

"It is usually not necessary to measure both serum amylase and lipase. Serum lipase may be preferable because it remains normal in some nonpancreatic conditions that increase serum amylase including macroamylasemia, parotitis, and some carcinomas. In general, serum lipase is thought to be more sensitive and specific than serum amylase in the diagnosis of acute pancreatitis" ^[2]

"Although amylase is widely available and provides acceptable accuracy of diagnosis, where lipase is available it is preferred for the diagnosis of acute pancreatitis (recommendation grade A)"^[3]

Most (PMID 15943725, PMID 11552931, PMID 2580467, PMID 2466075, PMID 9436862), but not all (PMID 11156345, PMID 8945483) individual studies support the superiority of the lipase. In one large study, there were no patients with pancreatitis who had an elevated amylase with a normal lipase ^[4]. Another study found that the amylase could add diagnostic value to the lipase, but only if the results of the two tests were combined with a discriminant function equation ^[5].

CT abdomen

Regarding the need for CT scanning, practice guidelines state:

2006: "Many patients with acute pancreatitis do not require a CT scan at admission or at any time during the hospitalization. For example, a CT scan is usually not essential in patients with recurrent mild pancreatitis caused by alcohol. A reasonable indication for a CT scan at admission (but not necessarily a CT with IV contrast) is to distinguish acute pancreatitis from another serious intra-abdominal condition, such as a perforated ulcer." ^[2]

2005: "Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6–10 days after admission will require CT (recommendation grade B)."^[3]

CT abdomen should not be performed before the 1st 48 hours of onset of symptoms as early CT (<48 h) may result in equivocal or normal findings.

CT Findings can be classified into the following categories for easy recall :

• Intrapancreatic - diffuse or segmental enlargement, edema, gas bubbles, pancreatic pseudocysts and phlegmons/abscesses (which present 4 to 6 wks after initial onset)
• Peripancreatic / extrapancreatic - irregular pancreatic outline, obliterated peripancreatic fat, retroperitoneal edema, fluid in the lessar sac, fluid in the left anterior pararenal space
• Locoregional - Gerota's fascia sign (thickening of inflamed Gerota's fascia, which becomes visible), pancreatic ascites, pleural effusion (seen on basal cuts of the pleural cavity), adynamic ileus,

Balthazar scoring

Balthazar Scoring for the Grading of Acute Pancreatitis

• Grade A - normal CT
• Grade B - focal or diffuse enlargement of the pancreas
• Grade C - pancreatic gland abnormalities and peripancreatic inflammation
• Grade D - fluid collection in a single location
• Grade E - two or more collections and/or gas bubbles in or adjacent to pancreas

Classification by severity

Progression of pathophysiology

Acute pancreatitis can be further divided in mild and severe pancreatitis. Mostly the Atlanta classification (1992) is used. In severe pancreatitis serious amount of necrosis determine the further clinical outcome. About 20% of the acute pancreatitis are severe with a mortality of about 20%. This is an important classification as severe pancreatitis will need intensive care therapy whereas mild pancreatitis can be treated on the common ward.

Necrosis will be followed by a systemic inflammation response syndrome (SIRS) and will determine the immediate clinical course. The further clinical course is then determined by bacterial infection. SIRS is the cause bacterial translocation from the patients colon.

There are several ways to help distinguish between these two forms. One is the above mentioned Ranson Score.

Prognostic indices

In predicting the prognosis, there are several scoring indices that have been used as predictors of survival. Two such scoring systems are the Ranson and APACHE II (Acute Physiology, Age and Chronic Health Evaluation) indices. Most^{[6] [7]}, but not all ^[8] studies report that the Apache score may be more accurate. In the negative study of the Apache II ^[8], the Apache II 24 hr score was used rather than the 48 hour score. In addition, all patients in the study received at ultrasound twice which may have influenced allocation of co-interventions. Regardless, only the Apache II can be fully calculated upon admission. As the Apache II is more cumbersome to calculate, presumably patients whose only laboratory abnormality is an elevated lipase or amylase do not need prognostication with the Apache II; however, this approach is not studied. The Apache I] score can be calculated at www.sfar.org. APACHE II is a well validated system for rating the severity of medical illness. ...

Practice guidelines state:

2006: "The two tests that are most helpful at admission in distinguishing mild from severe acute pancreatitis are APACHE-II score and serum hematocrit. It is recommended that APACHE-II scores be generated during the first 3 days of hospitalization and thereafter as needed to help in this distinction. It is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscitation."^[2]

2005: "Immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and APACHE II score" ^[3]

Ranson

Ranson's Criteria on Admission :

• age greater than 55 years
• a white blood cell count of > 16,000/µL
• blood glucose > 11 mmol/L (>200 mg/dL)
• serum LDH > 350 IU/L
• serum AST >250 IU/L

Ranson's Criteria after 48 hours of admission :

• fall in hematocrit by more than 10 percent
• fluid sequestration of > 6 L
• hypocalcemia (serum calcium < 2.0 mmol/L (<8.0 mg/dL))
• hypoxemia (P_O2 < 60 mmHg)
• increase in BUN to >1.98 mmol/L (>5 mg/dL) after IV fluid hydration
• base deficit of >4 mmol/L

The prognostic implications of Ranson's criteria are as follows :

• Score 0 to 2 : 2% mortality
• Score 3 to 4 : 15% mortality
• Score 5 to 6 : 40% mortality
• Score 7 to 8 : 100% mortality

APACHE

"Acute Physiology And Chronic Health Evaluation" (APACHE II) score > 8 points predicts 11% to 18% mortality ^[2] Online calculator APACHE II is a well validated system for rating the severity of medical illness. ...

• Hemorrhagic peritoneal fluid
• Obesity
• Indicators of organ failure
• Hypotension (SBP <90 mmHG) or tachycardia > 130 beat/min
• PO₂ <60 mmHg
• Oliguria (<50 mL/h) or increasing BUN and creatinine
• Serum calcium < 1.90 mmol/L (<8.0 mg/dL) or serum albumin <33 g/L (<3.2.g/dL)>

In physiology and medicine, hypotension refers to an abnormally low blood pressure. ... This article or section does not cite its references or sources. ... Oliguria and anuria are the decreased or absent production of urine, respectively. ... A Swedish-style saffron bun traditionally consumed en masse with Christmas at hand. ... Chemical structure of creatinine. ...

Treatment

General measures

• Supportive for shock.
• Pain relief

The following have no role in the management of acute pancreatitis

• Enzyme inhibitors are not proven to work.
• The use of octreotide has not been shown to improve outcome.

In the management of acute pancreatitis, the treatment is to stop feeding the patient, giving him or her nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest. Somatostatin is a hormone. ... An intravenous drip in a hospital Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. ... Dehydration (hypohydration) is the removal of water (hydro in ancient Greek) from an object. ... Ribbon diagram of the enzyme TIM, surrounded by the space-filling model of the protein. ...

Recently, there has been a shift in the management paradigm from TPN (total parenteral nutrition) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). The advantage of enteral feeding is that it is more physiological, prevents gut mucosal atrophy, and is free from the side effects of TPN (such as fungemia). The additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration. Disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the bronchus even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent NG tube entry into the trachea). Total parenteral nutrition (TPN), is the practice of feeding a person intravenously, circumventing the gut. ...

Antibiotics

A meta-analysis by the Cochrane Collaboration concluded that antibiotics help with a number needed to treat of 11 patients to reduce mortality ^[9]. However, the one study in the meta-analysis that used a quinolone, and a subsequent randomized controlled trial that studied ciprofloxacin were both negative ^[10]. A meta-analysis is a statistical practice of combining the results of a number of studies. ... The Cochrane Collaboration developed in response to Archie Cochranes call for systematic, up-to-date reviews (currently known as systematic reviews) of all relevant randomized clinical trials of health care. ... The number needed to treat (NNT) is an epidemiological measure that indicates how many patients would require treatment with a form of medication to reduce the expected number of cases of a defined endpoint by one. ... A meta-analysis is a statistical practice of combining the results of a number of studies. ... A randomized controlled trial (RCT) is a form of clinical trial, or scientific procedure used in the testing of the efficacy of medicines or medical procedures. ... Ciprofloxacin is the generic international name for the synthetic antibiotic manufactured and sold by Bayer Pharmaceutical under the brand names Cipro and Ciproxin (and other brand names in other markets, e. ...

In summary, the role of antibiotics is controversial. One recent expert opinion suggested the use of imipenem if CT scan showed mored than 30% necrosis of the pancreas ^[11] Imipenem is an intravenous beta-lactam antibiotic developed in 1985. ...

ERCP

Early ERCP (endoscopic retrograde cholangiopancreatography), performed within 24 hours of presentation, is known to reduce morbidity and mortality^{[citation needed]}. The indications for early ERCP are as follows : Endoscopic retrograde cholangiopancreatography (ERCP) is endoscopy of the biliary tree and the pancreatic duct. ...

• Clinical deterioration or lack of improvement after 24 hours
• Detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on CT abdomen

The disadvantages of ERCP are as follows :

• ERCP precipitates pancreatitis, and can introduce infection to sterile pancreatitis
• The inherent risks of ERCP i.e. bleeding

It is worth noting that ERCP itself can be a cause of pancreatitis.

Surgery

Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii)complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria

• Gas bubbles on CT scan (present in 20 to 50% of infected necrosis)
• Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas.

Surgical options for infected necrosis include:

• Conventional management - necrosectomy with simple drainage
• Closed management - necrosectomy with closed continuous lavage
• Open management - necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases)

Complications

Complications can be systemic or locoregional.

• Systemic complications include ARDS, multiple organ dysfunction syndrome, DIC, hypocalcemia (from fat saponification), hyperglycemia and insulin dependent diabetes mellitus (from pancreatic insulin producing beta cell damage)
• Locoregional complications include pancreatic pseudocyst and phlegmon / abscess formation, splenic artery pseudoaneurysms, hemorrhage from erosions into splenic artery and vein, thrombosis of the splenic vein, superior mesenteric vein and portal veins (in descending order of frequency), duodenal obstruction, common bile duct obstruction, progression to chronic pancreatitis

Acute respiratory distress syndrome (ARDS), also known as respiratory distress syndrome (RDS) or adult respiratory distress syndrome (in contrast with IRDS) is a serious reaction to various forms of injuries to the lung. ... Multiple organ dysfunction syndrome MODS; previously known as multiple organ failure (MOF) is altered organ function in an acutely ill patient requiring medical intervention to maintain homeostasis. ... Disseminated intravascular coagulation (DIC) is a pathological process in the body where the blood starts to coagulate throughout the whole body. ... In medicine, hypocalcaemia is the presence of less than a total calcium of 2. ... Hyperglycemia or High Blood Sugar is a condition in which an excessive amount of glucose circulates in the blood plasma. ... For the disease characterized by excretion of large amounts of very dilute urine, see diabetes insipidus. ... Beta cells are a type of cell in the pancreas in areas called the islets of Langerhans. ...

Epidemiology

• Annual incidence in the U.S. is 18 per 100,000 population. [1]
• Prevalence in the US is 80,000 cases per year.

Motto: (Out Of Many, One) (traditional) In God We Trust (1956 to date) Anthem: The Star-Spangled Banner Capital Washington D.C. Largest city New York City None at federal level (English de facto) Government Federal constitutional republic  - President George Walker Bush (R)  - Vice President Dick Cheney (R) Independence from...

See also

• Chronic pancreatitis

Chronic pancreatitis can present as episodes of acute inflammation in a previously injured pancreas, or as chronic damage with persistent pain or malabsorption. ...

References

1. ^ Gumaste V, Dave P, Weissman D, Messer J (1991). "Lipase/amylase ratio. A new index that distinguishes acute episodes of alcoholic from nonalcoholic acute pancreatitis". Gastroenterology 101 (5): 1361-6. PMID 1718808. 
2. ^ ^{a b c d} Banks P, Freeman M (2006). "Practice guidelines in acute pancreatitis". Am J Gastroenterol 101 (10): 2379-400. DOI:10.1111/j.1572-0241.2006.00856.x. PMID 17032204. 
3. ^ ^{a b c} UK Working Party on Acute Pancreatitis (2005). "UK guidelines for the management of acute pancreatitis". Gut 54 Suppl 3: iii1-9. DOI:10.1136/gut.2004.057026. PMID 15831893. 
4. ^ Smith R, Southwell-Keely J, Chesher D (2005). "Should serum pancreatic lipase replace serum amylase as a biomarker of acute pancreatitis?". ANZ J Surg 75 (6): 399-404. DOI:10.1111/j.1445-2197.2005.03391.x. PMID 15943725. 
5. ^ Corsetti J, Cox C, Schulz T, Arvan D (1993). "Combined serum amylase and lipase determinations for diagnosis of suspected acute pancreatitis". Clin Chem 39 (12): 2495-9. PMID 7504593. 
6. ^ Larvin M, McMahon M (1989). "APACHE-II score for assessment and monitoring of acute pancreatitis". Lancet 2 (8656): 201-5. PMID 2568529. 
7. ^ Yeung Y, Lam B, Yip A (2006). "[www.hbpdint.com/text.asp?id=837 APACHE system is better than Ranson system in the prediction of severity of acute pancreatitis]". Hepatobiliary Pancreat Dis Int 5 (2): 294-9. PMID 16698595. 
8. ^ ^{a b} Chatzicostas C, Roussomoustakaki M, Vlachonikolis I, Notas G, Mouzas I, Samonakis D, Kouroumalis E (2002). "Comparison of Ranson, APACHE II and APACHE III scoring systems in acute pancreatitis". Pancreas 25 (4): 331-5. PMID 12409825 (comment=this study used a Apache cutoff of >=10). 
9. ^ Villatoro E, Bassi C, Larvin M. "Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis". Cochrane Database Syst Rev: CD002941. PMID 17054156. 
10. ^ Isenmann R, Rünzi M, Kron M, Kahl S, Kraus D, Jung N, Maier L, Malfertheiner P, Goebell H, Beger H (2004). "Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial". Gastroenterology 126 (4): 997-1004. DOI:10.1053/j.gastro.2003.12.050. PMID 15057739. 
11. ^ Whitcomb D (2006). "Clinical practice. Acute pancreatitis". N Engl J Med 354 (20): 2142-50. DOI:10.1056/NEJMcp054958. PMID 16707751. 

A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ...

External links

• Medical Information and Treatment of Acute Pancreatitis
• Mechanisms of Disease: Etiology and Pathophysiology of Acute Pancreatitis