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Acute pancreatitis

Medicine > Gastrointestinal

Background knowledge 🧠

Definition

  • Acute inflammation of the pancreas, often reversible with timely management
  • Characterised by autodigestion of pancreatic tissue by enzymes
  • Ranges in severity from mild self-limiting disease to severe necrotising pancreatitis

Epidemiology

  • Incidence: 15-40 cases per 100,000 per year in the UK
  • Most common in middle-aged adults
  • More prevalent in males (due to alcohol aetiology)
  • Increasing incidence over recent decades due to rising alcohol consumption and obesity rates

Aetiology and Pathophysiology

  • Gallstones (40-70% of cases)
  • Alcohol (25-35%)
  • Hypertriglyceridaemia, trauma, post-ERCP, infections, and medications
  • Autodigestion by pancreatic enzymes (trypsinogen activated to trypsin)
  • Inflammatory mediators lead to local and systemic inflammation

Types

  • Interstitial oedematous pancreatitis (milder form, minimal necrosis)
  • Necrotising pancreatitis (severe, areas of necrosis in pancreas)
  • Severe pancreatitis can be complicated by local or systemic infection
  • Classified according to severity (mild, moderate, severe) based on clinical features and imaging

Clinical Features 🌡️

Symptoms

  • Severe epigastric pain, radiating to the back
  • Nausea and vomiting
  • Pain may be relieved by sitting forward
  • Symptoms typically develop suddenly after a heavy meal or alcohol intake
  • Anorexia, fever, and fatigue may accompany

Signs

  • Tenderness in epigastric region
  • Abdominal guarding and rebound tenderness in severe cases
  • Fever and tachycardia (systemic inflammatory response)
  • Hypotension and shock in severe cases
  • Cullen’s sign (periumbilical bruising) or Grey-Turner’s sign (flank bruising) in severe necrotising pancreatitis

Investigations 🧪

Tests

  • Serum amylase or lipase: elevated (lipase more specific)
  • FBC: leukocytosis
  • LFTs: elevated if biliary obstruction (gallstones)
  • CRP and urea: assess severity
  • Abdominal ultrasound: to detect gallstones
  • CT scan: for diagnosing complications and necrosis

Management 🥼

Management

  • Supportive care: IV fluids, pain relief (opiates), and antiemetics
  • Nil by mouth in early stages; nasogastric tube if vomiting
  • Treatment of underlying cause (e.g., ERCP for gallstones)
  • Antibiotics only if infection is suspected
  • Consider ICU care in severe cases with multiorgan failure
  • Early nutritional support (enteral feeding preferred)

Complications

  • Local: necrosis, pseudocyst, abscess
  • Systemic: ARDS, renal failure, DIC
  • Chronic pancreatitis may develop
  • Death in severe cases (10-20% mortality in necrotising pancreatitis)

Prognosis

  • 80-90% of patients recover fully with supportive care
  • Mortality is higher in severe cases with multiorgan failure
  • Recurrence is common, especially if underlying causes are not addressed
  • Chronic pancreatitis can develop with recurrent attacks

Key Points

  • Common causes: gallstones, alcohol, hypertriglyceridaemia
  • Serum lipase is more specific than amylase
  • Management is largely supportive, but underlying causes must be treated
  • Complications include necrosis, ARDS, and chronic pancreatitis
  • Early recognition and treatment improve outcomes

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Gastrointestinal