Acute Pancreatitis: Causes, Diagnosis and Management

Acute pancreatitis is sudden inflammation of the pancreas. Most cases are mild and settle within a week, but about one in five patients develops severe disease with organ failure, which carries a significant risk of death. Early recognition and good supportive care are the keys.

Causes

The two commonest causes are gallstones and alcohol. A popular memory aid is "I GET SMASHED":

• Idiopathic
• Gallstones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps and other infections
• Autoimmune
• Scorpion venom
• Hypertriglyceridaemia, hypercalcaemia and hypothermia
• ERCP
• Drugs, for example azathioprine, valproate and thiazides

Clinical features

• Severe, constant epigastric pain, often radiating to the back and relieved by sitting forward.
• Nausea and vomiting.
• Epigastric tenderness.
• Tachycardia and fever.
• In severe cases:
  • shock
  • breathlessness
  • flank bruising (Grey Turner's sign)
  • periumbilical bruising (Cullen's sign)

Diagnosis (revised Atlanta classification)

Two of the following three:

1. Typical abdominal pain.
2. Serum lipase or amylase at least three times the upper limit of normal. Lipase is more specific.
3. Characteristic findings on imaging.

Other investigations:

• Ultrasound of the abdomen to look for gallstones.
• Blood tests: full blood count, kidney and liver function, calcium, triglycerides, glucose and CRP.
• Arterial blood gases.
• Contrast CT if the diagnosis is uncertain, or after 72 hours to assess complications in patients who are not improving.

Severity

• Mild: no organ failure or local complications.
• Moderately severe: transient organ failure (resolving within 48 hours) or local complications.
• Severe: persistent organ failure lasting more than 48 hours.

Scoring systems such as Glasgow-Imrie, APACHE II and BISAP, together with CRP, help predict severity.

Management

• Fluid resuscitation: goal-directed IV fluids, often Ringer's lactate. Avoid both under- and over-hydration, and monitor urine output.
• Analgesia: adequate pain relief, including opioids where needed.
• Early oral or enteral feeding as tolerated, rather than prolonged fasting.
• Antibiotics are not recommended routinely. Use them only for proven or strongly suspected infection, such as infected necrosis or cholangitis.
• Gallstone pancreatitis: urgent ERCP if there is cholangitis. In mild disease, cholecystectomy during the same admission to prevent recurrence.
• Severe disease: high-dependency or intensive care, and a multidisciplinary team.

Complications

• Systemic:
  • ARDS
  • acute kidney injury
  • shock
  • hypocalcaemia
  • hyperglycaemia
  • disseminated intravascular coagulation
• Local:
  • acute peripancreatic fluid collections
  • pancreatic necrosis (which may become infected)
  • pseudocysts
  • walled-off necrosis
  • splenic or portal vein thrombosis

Exam pearls

• Amylase level does not correlate with severity.
• Hypocalcaemia is a poor prognostic sign.
• A pseudocyst is a collection lasting more than 4 weeks, with a wall but no epithelial lining.

See also Gallstones and Cholecystitis, our Surgery Companion and Exam Night Notes 1.0: Gastro Surgery.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Two commonest causes of acute pancreatitis:

   1. Scorpion venom and drugs
   2. Gallstones and alcohol
   3. Trauma and ERCP
   4. Mumps and steroids
   5. Hypercalcaemia and hypothermia
   Show answer

   Answer: B. Gallstones and alcohol
   Gallstones and alcohol together cause most cases.

2. Diagnostic threshold of serum lipase or amylase:

   1. 10 times normal
   2. Any rise
   3. Below normal
   4. Above normal
   5. At least 3 times the upper limit of normal
   Show answer

   Answer: E. At least 3 times the upper limit of normal
   Revised Atlanta: enzyme ≥3× ULN is one of the three criteria.

3. Which statement about amylase is correct?

   1. Always normal in pancreatitis
   2. More specific than lipase
   3. Level predicts severity
   4. Only raised in alcohol cases
   5. Level does not correlate with severity
   Show answer

   Answer: E. Level does not correlate with severity
   Enzyme levels do not reflect severity; use clinical scores and organ failure.

4. Routine prophylactic antibiotics in acute pancreatitis are:

   1. Given for 6 weeks
   2. Only for mild cases
   3. Not recommended; use only for proven or suspected infection
   4. Recommended for all
   5. Required before feeding
   Show answer

   Answer: C. Not recommended; use only for proven or suspected infection
   Antibiotics are for infected necrosis, cholangitis or other confirmed infection.

5. Severe acute pancreatitis is defined by:

   1. Fever
   2. Amylase above 1000
   3. Persistent organ failure lasting more than 48 hours
   4. Pain lasting over 24 hours
   5. Gallstones on ultrasound
   Show answer

   Answer: C. Persistent organ failure lasting more than 48 hours
   Revised Atlanta: severe disease = persistent organ failure (>48 h).

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.