Update on pathogenesis and clinical management of acute pancreatitis

Table 1 Causes of acute pancreatitis[6,9]

Etiology of acute pancreatitis
Toxic-metabolic	Alcohol Hyperlipidemia, hypercalcemia Drugs and pills Organophosphorus and other toxic substances Venoms (scorpion, spiders)
Mechanical	Biliary: lithiasis, microlithiasis, sludge Congenital malformations Pancreas divisum Annular pancreas Anatomical variants: Duodenal duplication Duodenal diverticulum Choledochal cyst Ampullary dysfunction and stenosis Trauma
Genetic	Familial Sporadic
Miscellanea	Vascular Hypotension Vasculitis Embolisms Hypercoagulability Autoimmune associated to other autoimmune disorders Sjögren syndrome Primary sclerosing cholangitis Celiac disease Autoimmune hepatitis Infections: Virus: mumps, Coxsackie A, HIV, CMV Bacteria: Mycobacterium tuberculosis Parasites: Ascaris Other: Mycoplasma Idiopathic

HIV: Human immunodeficiency virus; CMV: Cytomegalo virus.

Table 2 Definitions for acute pancreatitis according to the Atlanta classification[1,6]

Criteria of illness severity in acute pancreatitis
Local complications	Necrosis: focal or diffuse area of non viable pancreatic parenchyma, with necrosis of peripancreatic fat (> 30% of the gland or > 3 cm) Pseudocyst: pancreatic juice collection surrounded by a wall of granulation or fibrous tissue that is developed as a consequence of acute or chronic pancreatitis or pancreatic traumatism Abscess: pus collection well defined that has scarce or no amount of pancreatic necrosis
Systemic complications (organic failure)	Respiratory failure: PaO2 < 60 mmHg Shock: systolic BP < 90 mmHg Renal failure: creatinine > 2 mg/dL after rehydration Upper gastrointestinal bleeding: > 500 mL/24 h
Bad prognosis data	Ranson’s scale ≥ 3 APACHE II scale ≥ 8

APACHE: Acute physiology and chronic health evaluation.

Table 3 The bedside index for severity in acute pancreatitis prognosis system[25]

Parameters
Blood urea nitrogen	BUN > 25 mg/dL
Impaired mental status	Conscious status impairment
Systemic inflammatory response	SIRS criteria presence1
Age	> 60 yr
Pleural effusion	Pleural effusion at X ray

¹Systemic inflammatory response syndrome: presence of ≥ 2 criteria. Heart rate > 90 bpm; Temperature > 38 ºC or < 36 ºC; Respiratory rate > 20 bpm or PaCO2 < 32 mmHg; Leucocytes > 12.000 or < 4.000/mm3 or > 10% immature forms. BUN: blood urea nitrogen; SIRS: Systemic inflammatory response syndrome.

Table 4 Balthazar score system[26]

Grade	Computer tomography findings
A	Normal pancreas
B	Pancreatic focal or diffuse bigger size, including irregular contour or nonhomogeneous attenuation
C	Grade B + pancreatic inflammation
D	Grade C + fluid collection
E	Grade D + 2 or more fluid collections with or without the presence of gas in the pancreas or next to it

Table 5 Computer tomography index of illness severity for acute pancreatitis[27]

Balthazar’s CT grade	Score	Necrosis at CT (%)	Score
A	0	None	0
B	1	< 30	2
C	2	30-50	4
D	3	> 50	6
E	4	-	-

CT index is obtained by the sum of the score obtained applying the Balthazar scale plus the score corresponding to the percentage of necrosis (maximum score = 10). CT: Computer tomography.