Evaluation and management of acute pancreatitis

Table 1 Etiologies of acute pancreatitis

Etiology	Incidence
Gallstones	28%-38%
Alcohol related	19%-41%
Hypertriglyceridemia	1%-4%
Idiopathic	10%-40%
Drug	2%-4.8%
Trauma	1%
Infectious
Post-ERCP
Hypercalcemia
Vascular
Genetic

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 2 Scoring systems for assessing severity of acute pancreatitis

Atlanta Revision (2013)	Ranson’s Criteria	BISAP
Mild acute	After 24 h of admission	Within 24 h of admission
(1) Absence of organ failure; (2) Absence of local complications	Age greater than 55; WBC > 16000; Blood Glucose > 200 mg/dL; Serum LD > 350 IU/L; Serum AST > 250/L	(1) BUN > 25 mg/dL; (2) Impaired mental status; (3) Systemic inflammatory response syndrome (SIRS); (4) Age > 60; (5) Presence of a pleural effusion
Moderately severe	After 48 h of admission
(1) Local complicationsa and/or (2) transient organ failureb for less than 48 h	Fall in Hematocrit > 10%; Fluid Sequestration > 6L; Hypocalcemia < 8 mg/dL; Hypoxemia; Increase in BUN of > 5 mg/dL after IV fluid; Base deficit of > 4 mmol/L
Severe	Mortality based on score	Mortality based on score
Persistent organ failure for greater than 48 h	Score of 0 to 2: 0%-3%; Score of 3 to 5: 11%-15%; Score of 6 to 11: 40%	Score of 0: 0.1%-0.2%; Score of 1: 0.5%-0.7%; Score of 2: 1.9%-2.1%; Score of 3: 5.3%-8.3%; Score of 4: 12.7%-19.3%; Score of 5: 22.5%-26.7%

^aLocal Complications: Interstitial edematous pancreatitis, necrotizing pancreatitis, pancreatic pseudocyst, acute necrotic collection, walled off necrosis, and pleural effusion. ^bOrgan Failure: Failure of main organ systems - respiratory, cardiac, renal, hepatic, hematological, neurological. WBC: White blood cells; LD: Lactate dehydrogenase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; BISAP: Bedside Index of Severity in Acute Pancreatitis.

Table 3 Complications of acute pancreatitis

Region	Complications	Manifestation
Local	Interstitial Edematous Pancreatitis	Description: Acute inflammation of parenchyma or peripancreatic tissues; Radiology: Enhancement of the pancreatic parenchyma with no signs of necrosis
	Necrotizing Pancreatitis	Description: Necrosis encompassing pancreatic parenchyma or pancreatic tissues; Radiology: Acute necrotic collection lacking definable wall containing variable amounts of fluid OR Walled off necrosis containing a well-defined encapsulated collection
	Acute peripancreatic Fluid Collection	Description: Homogenous collection of fluids with no distinct inflammatory walls outside pancreas containing minimal or no necrosis; Timing: Within the first four weeks after onset of interstitial edema; Radiology: Homogenous collection with fluid confined by normal fascial planes
	Pancreatic Pseudocyst	Description: Collections of fluids that contain distinct inflammatory walls outside the pancreas containing minimal to no necrosis; Timing: After four weeks of initial onset of interstitial edematous pancrea-titis; Radiology: Clear homogenous fluid density with well-defined borders that is encapsulated
	Acute Necrotic Collection	Description: Collection of both fluid and necrosis associated with necrotizing pancreatitis; Radiology: intrapancreatic or extrapancreatic heterogenous non-liquid density of varying degrees with no definite wall
	Walled Off Necrosis	Description: Encapsulated collection of pancreatic or peripancreatic necrosis that has formed a distinct inflammatory wall; Radiology: Heterogenous liquid/non-liquid density with varying loculations. The structure has a well demarcated wall that is en-tirely encapsulated
Peripancreatic	Thrombosis	Description: Thrombosis of splanchnic venous circulation including splenic vein, portal and/or superior mesenteric veins
	Pseudoaneurysm	Description: Collection of blood forming between the two most outer layer of the artery – muscularis propria and adventitia
	Abdominal Compartment Syndrome	Description: Tissue edema that is secondary to aggressive fluid resuscitation, peripancreatic inflammation and ascites