1. Dr Arth Shah, Resident, Dept of Surgery,
karamsad Medical college
Dr Manoj K Ghoda M.D., M.R.C.P.
Consultant Gastroenterologist

2. 22 years old male
 Sudden onset of epigastric pain radiating to back
 No significant past history
 No drugs, no alcohol, no heavy meals
 On examination:
 In pain
 Pulse 82/min, B.P.120/80
 RR: 16/min, no cyanosis
 Abdomen: Tenderness +, no guarding, No rigidity,
peristalses +

3. ? Acute pancreatitis:
Issues:
1. Diagnosis
2. Defining various terminology
3. Assessing severity
4. Role of antibiotics
5. Role of nutrition
6. Role of surgery

4. ? Acute pancreatitis: Diagnosis
 Investigations
 Blood
 Amylase
 Lipase

5. Diagnosis
 Amylase and lipase are the cornerstone lab
parameters for the diagnosis.
 "It is usually not necessary to measure
both amylase and lipase (3).

6. Diagnosis
 Lipase may be preferable
 It remains normal in some nonpancreatic
conditions that increase serum amylase including
macroamylasemia, parotitis, and some carcinomas.
 Lipase is thought to be more sensitive and specific
and superior to amylase[3, 4, 5]
 In one large study, there were no patients with
pancreatitis who had an elevated amylase with a
normal lipase [5].

7. Diagnosis
 Lipase starts to rise by 4-8 hours, peaks in
24 hours and normalizes by 8- 14 days.

8. Amylase and Lipase
 Higher the numerical value more certain
is the diagnosis.
 Although severe pancreatitis could also exist
without significant rise in these enzymes.
 Numerical value of these enzymes have no
prognostic value and neither they
reflect severity

9. Diagnosis: Imaging
 USG is cornerstone
 CT
 MR
 EUS/ ERCP 100 acute pancreatitis….20% severe= 20
20% of severe become infected= 4
Infection usually sets in 2nd week or 3rd week
Surgeons would want to delay surgery till
about 4 weeks
Infected necrosis will always be clinically
manifest
So why CT scan in first week ????

10. Issues:
Assessing severity at the bedside
 Clinical features
 Scoring systems

11. Clinical features useful in
assessing severity
 Toxic Look
 Severe pain
 Persistent tachycardia
 Breathlessness and
Cyanosis
 Sub-normal
temperature
 Shock
 Normal look
 Mild pain
 Normal Pulse rate
 Normal Oxygen
saturation
 Adequate urine output
 Flat and soft and
movable abdomen

12. Acute Necrotizing Pancreatitis
ACG Practice Guidelines

13. Bedside index of severity in acute
pancreatitis (BISAP) score
This calculator evaluates the following Clinical Criteria:
 BUN >25 mg/dL (8.9 mmol/L)
 Impairment of mental status with a Glasgow coma score
<15
 SIRS (systemic inflammatory response syndrome)
 Age >60 years old
 Pleural effusion
Each determinant is given one point
The MedCalc 3000 module Bedside index of severity in acute pancreatitis (BISAP) score is available in MedCalc 3000 Complete Edition.
SIRS is defined as 2 or more of the following variables;
 Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F)
 Heart rate of more than 90 beats per minute
 Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32mm Hg
 Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms)

14. BISAP Score BISAP Score Observed Mortality
 0 0.1%
 1 0.4%
 2 1.6%
 3 3.6%
 4 7.4%
 5 9.5%
Wu et al, Gut 2008

15. BISAP scores of 3 predict the development of organ failure,
persistent organ failure, and necrosis in the prospective cohort
of 397 cases
A Prospective Evaluation of the Bedside Index for Severity in Acute Pancreatitis Score in Assessing Mortality and Intermediate Markers
of Severity in Acute Pancreatitis
Vikesh K Singh, Bechien U Wu, Thomas L Bollen, Kathryn Repas, Rie Maurer, Richard S Johannes, Koenraad J Mortele, Darwin L Conwell and Peter A
Banks. Am L Gastroenterol
BISAP<3 BISAP>3 OR (95%
CI)
p
Organ
failure
4 23 7.4 <0.0001
Persistent
OF
2 21 12.7 <0..0001
Necrosis 12 34 3,8 0.0004

16. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in
predicting organ failure, complications, and mortality in acute
pancreatitis.
Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. Am J Gastroenterol. 2010
Feb;105(2):435-41; quiz 442. doi: 10.1038/ajg.2009.622. Epub 2009 Oct 27
CONCLUSIONS:
 BISAP score is an accurate means for risk stratification
in patients with AP.
 Its components are clinically relevant and easy to
obtain.
 The prognostic accuracy of BISAP is similar to those of
the other scoring systems.

17. Acute Pancreatitis
Issue:
Definitions of various disease determinants

18. Classification of acute pancreatitis--2012:
Revision of the Atlanta classification and
definitions by international consensus.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute
Pancreatitis Classification Working Group.
Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25

19. Determinants of revised Atlanta
classification
 Local
 Pancreatic or peripancreatic fluid collection
 Sterile
 Infected
 Necrosis
 Sterile
 Infected
 Pseudocyst and walled-off necrosis (sterile or infected).
 Organ failure

20. Local Complications
After 4 weeks

21. Local Complications
Infection

24. Revised Atlanta......
 Acute pancreatitis identified two phases of the disease:
early and late.
 Severity is classified as mild, moderate or severe.
 Mild:
 the most common form,
 has no organ failure, local or systemic complications and
 usually resolves in the first week.
 Moderate:
 Presence of transient organ failure, local complications or
exacerbation of co-morbid disease.
 Severe:
 Persistent organ failure >48 h.
 Local complications are peripancreatic fluid collections, pancreatic
and peripancreatic necrosis (sterile or infected),

25. Objections to revised Atlanta
classification
 Mere presence of fluid or necrosis do not determine the outcome
 It is the infection that determines the outcome
 A number of studies have demonstrated that infectious
(peri)pancreatic complications (IPCs), rather than the presence
of necrosis per se, are a key determinant of the high morbidity
and mortality in patients with acute pancreatitis. (Büchler MW, Gloor B,
Müller CA et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg
2000;232:619–626. | Article | PubMed | ISI | ChemPort |Lytras D, Manes K, Triantopoulou C et al. Persistent early
organ failure: defining the high-risk group of patients with severe acute pancreatitis? Pancreas 2008;36:249–254. |
Article | PubMed) ,Le Mée J, Paye F, Sauvanet A et al. Incidence and reversibility of organ failure in the course of sterile
or infected necrotizing pancreatitis. Arch Surg 2001;136:1386–1390. | Article | PubMed
 Mere organ failure does not determine the outcome
 It is the rapidity, the severity, reversibility and number of organs
affected that determines the outcome (5,6,7,8,9)

26. Determinant-based classification
of acute pancreatitis severity: an
international multidisciplinary
consultation
.
Dellinger EP, Forsmark CE, Layer P, Lévy P, Maraví-Poma E, Petrov MS, Shimosegawa T, Siriwardena AK,
Uomo G, Whitcomb DC, Windsor JA; Pancreatitis Across Nations Clinical Research and Education
Alliance (PANCREA). Ann Surg. 2012 Dec;256(6):875-80. doi: 10.1097/SLA.0b013e318256f778

27.  The presence of one determinant can modify the effect
of another such that the presence of both infected
(peri)pancreatic necrosis and persistent organ failure
have a greater effect on severity than either
determinant alone.
 The derivation of a classification based on the above
principles results in 4 categories of severity-mild,
moderate, severe, and critical.

28. Critical Pancreatitis

29. Acute Pancreatitis: Management
Issue
 Fluid replacement
 Vigorous hydration to optimize outcomes has been increasingly
recognized.
 The ACG guidelines stress, “Patients with evidence of significant
third-space losses require aggressive fluid resuscitation.”
 Many patients sequester substantial amounts of fluid into the
retroperitoneal space, producing very high fluid requirements.
 Intravascular volume depletion may lead to tachycardia,
hypotension, renal failure, hemoconcentration, and generalized
circulatory collapse.
 More than 6 L of fluid sequestration within the first 48 hours is
considered a marker of increased severity, according to the Ranson
criteria

30. Acute Pancreatitis:
Issues:
 Antibiotics
 Time frame:
 Severe pancreatitis can be observed in 15–20 % of all cases.
 The first two weeks after onset of symptoms are characterized
by the systemic inflammatory response syndrome
(SIRS).
 Pancreatic necrosis develops within the first 4 days after the
onset of symptoms to its full extent,
 Infection of pancreatic necrosis develops most
frequently in the 2nd and 3rd week

31. Acute pancreatitis and
antibiotics: Cochrane Review
Objectives:
 To determine the efficacy and safety of prophylactic
antibiotics in acute pancreatitis complicated by CT
proven pancreatic necrosis.

32. Main results:
 Seven evaluable studies randomised 404 patients.
 No statistically significant effect on reduction of mortality
with therapy: 8.4% versus controls 14.4%, and infected
pancreatic necrosis rates: 19.7% versus controls 24.4%.
 Non‐pancreatic infection rates and the incidence of overall
infections were not significantly reduced with antibiotics:
23.7% versus 36%; 37.5% versus 51.9% respectively.
 Operative treatment and fungal infections were not
significantly different. Insufficient data were provided
concerning antibiotic resistance.

33.  With beta‐lactam antibiotic prophylaxis there was less
mortality (9.4% treatment, 15% controls), and less
infected pancreatic necrosis (16.8% treatment group,
24.2% controls) but this was not statistically
significant.
 The incidence of non‐pancreatic infections was
non‐significantly different (21% versus 32.5%), as
was the incidence of overall infections (34.4% versus
52.8%), and operative treatment rates.

34.  No significant differences were seen with quinolone
plus imidazole in any of the end points measured.
 Imipenem on its own showed no difference in the
incidence of mortality, but there was a significant
reduction in the rate of pancreatic infection (p=0.02;
RR 0.34, 95% CI 0.13 to 0.84)

35. Authors' conclusions:
 No benefit of antibiotics in preventing infection of
pancreatic necrosis or mortality was found, except for
when imipenem (a beta‐lactam) was considered on its
own, where a significantly decrease in pancreatic
infection was found.
 None of the studies included in this review were
adequately powered. Further better designed studies
are needed if the use of antibiotic prophylaxis is to be
recommended

36. Acute Pancreatitis
Issue:
Other pathogenesis inhibiting drugs
 To date, inhibition of any known pathogenetic step
(that is, octreotide, gabexate mesilate, lexipafant) has
not effectively reduced mortality or increased long
term survival in severe acute pancreatitis.8,28–30

37. Acute Pancreatitis
Issues:
 Nutrition

38. Background facts..
 Nutritional management during acute pancreatitis has
• the purpose to avoid a negative influence on the outcome and to
preserve the morphofunctional integrity of the gut,
• preventing bacterial translocation.
• Preventing SIRS
• When the course of the disease is longer and the severity is
higher, an early artificial nutritional support is advisable.
• Caloric needs thought to be useful are 25-30 kcal/kg/d;
• 40-60% of nutrient mixture should consist of carbohydrates and
20-30% of lipids. Proteins should be approximately 1.0-1.5 g/kg/d
McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a
systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-56.

39. Fears….
 Enteral diets stimulate enzyme secretion unless
delivered below the jejunum.

40. Nutrition in Acute pancreatitis
Enteral versus parenteral nutrition for acute
pancreatitis. Cochrane Review.
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD002837. doi: 10.1002/14651858.CD002837.pub2.
Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA.
Intern Med. 2012;51(6):523-30. Epub 2012 Mar 15.
Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis.
Yi F, Ge L, Zhao J, Lei Y, Zhou F, Chen Z, Zhu Y, Xia B
Objectives:
 To compare the effect of TPN versus EN on mortality,
morbidity and length of hospital stay in patients with
acute pancreatitis.

41. Main results:
 Eight trials with a total of 348 participants were included.
 Comparing EN to TPN for acute pancreatitis,
 the relative risk (RR) for death was 0.50 (95% CI 0.28 to 0.91),
 for multiple organ failure (MOF) was 0.55 (95% CI 0.37 to
0.81),
 for systemic infection was 0.39 (95% CI 0.23 to 0.65),
 for operative interventions was 0.44 (95% CI 0.29 to 0.67),
 for local septic complications was 0.74 (95% CI 0.40 to 1.35),
and
 for other local complications was 0.70 (95% CI 0.43 to 1.13).

42.  Mean length of hospital stay was reduced by 2.37 days
in EN vs TPN groups (95% CI ‐7.18 to 2.44).
 Furthermore, a subgroup analysis for EN vs TPN in
patients with severe acute pancreatitis showed a RR for
death of 0.18 (95% CI 0.06 to 0.58) and a RR for MOF
of 0.46 (95% CI 0.16 to 1.29).

43. Authors' conclusions:
 In patients with acute pancreatitis, enteral nutrition
significantly reduced mortality, multiple organ failure,
systemic infections, and the need for operative
interventions compared to those who received TPN.
 In addition, there was a trend towards a reduction in
length of hospital stay.
 These data suggest that EN should be considered the
standard of care for patients with acute pancreatitis
requiring nutritional support.

44. Nutrition Support in Acute Pancreatitis: A Systematic
Review of the Literature
Stephen A. McClave, Wei-Kuo Chang, Rupinder Dhaliwal, Daren K. Heyland,
JPEN J Parenter Enteral Nutr MARCH-APRIL 2006 vol. 30 no. 2 143-156 doi: 10.1177/0148607106030002143
 Patients with acute severe pancreatitis should begin EN
early because such therapy modulates the stress response,
promotes more rapid resolution of the disease process, and
results in better outcome.
 In this sense, EN is the preferred route and has eclipsed PN
as the new “gold standard” of nutrition therapy. When PN
is used, it should be initiated after 5 days.
 Individual variability allows for a wide range of tolerance to
EN, even in severe pancreatitis

45. Nutrition in AP: NG or NJ?
Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and
tolerance.
Petrov MS, Correia MI, Windsor JA. JOP. 2008 Jul 10;9(4):440-8.
 CONTEXT: Nasogastric tube feeding is safe and well
tolerated in most critically ill patients. However, its
safety and tolerance in the setting of severe acute
pancreatitis is debatable.
 OBJECTIVE: to review all available studies on
nasogastric feeding in patients with severe acute
pancreatitis to determine the safety and tolerance of
this approach. A further aim was to perform a meta-
analysis of the available randomized controlled trials
regarding nasogastric versus nasojejunal feeding.

46. RESULTS:
 A total of four studies on nasogastric tube feeding in 92
patients with predicted severe acute pancreatitis were
identified.
 Documented infected pancreatic necrosis developed in 11
patients (16.9%) and multiple organ failure in 10 (15.4%)
out of 65 patients with available data.
 Overall, there were 15 deaths (16.3%).
 An exacerbation of pain after initiation of feeding occurred
in 3 (4.3%) out of 69 patients with available data.
 Full tolerance was achieved in 73 (79.3%) patients who did
not require temporary reduction, stoppage or withdrawal
of nasogastric feeding.

47. CONCLUSION:
 Nasogastric feeding appears safe and well
tolerated in patients with predicted severe acute
pancreatitis.
 An adequately powered randomized trial on
nasogastric versus nasojejunal feeding is required to
support this approach as routine clinical management.

48. Nasogastric or nasointestinal feeding in severe
acute pancreatitis.
Piciucchi M, Merola E, Marignani M, Signoretti M, Valente R, Cocomello L, Baccini F, Panzuto F, Capurso G, Delle Fave G.
World J Gastroenterol. 2010 Aug 7;16(29):3692-6.
AIM:
 To assess the rate of spontaneous tube migration and to
compare the effects of naso-gastric and naso-intestinal
(NI) (beyond the ligament of Treitz) feeding in severe acute
pancreatitis (SAP).
CONCLUSION:
 Spontaneous distal tube migration is successful in 40% of
SAP patients, with higher CT severity index predicting
intragastric retention;
 In such cases EN by NG tubes seems to provide a pragmatic
alternative opportunity with similar outcomes

49. Nutritional strategies in severe acute
pancreatitis: A systematic review of the
evidence.
Ahmad Al Samaraee, Iain J.D. McCallum, Peter E. Coyne, Keith Seymour
The Surgeon; Volume 8, Issue 2 , Pages 105-110, April 2010
 Evidence supports naso–jejunal enteral nutrition (NJ-EN) over
parenteral nutrition (PN) reducing infectious morbidity and showing a
trend towards reduced organ failure although there is no detectable difference
in mortality.
 NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often
impractical and naso-gastric (NG) feeding seems to be equivalent in terms of
safety and outcomes whilst being more practical (level 2 evidence).
 Regarding feed supplementation, probiotic feed supplementation is not
beneficial (level 1 evidence) the and may cause harm with excess mortality
(level 2 evidence).
 No evidence exists to confirm benefit of the addition of prokinetics in severe
acute pancreatitis (SAP) although their use is proven in other critically ill
patients.
 Level 2 evidence does not currently support the use of combination immuno-
nutrition though further work on individual agents may provide differing
results. Level 2 evidence does not support intravenous supplementation of
anti-oxidants and has demonstrated that these too may cause harm

50. Early nasogastric tube feeding versus nil per os in
mild to moderate acute pancreatitis: A
randomized controlled trial.
Petrov MS, McIlroy K, Grayson L, Phillips AR, Windsor JA. Clin Nutr. 2012 Dec 31. pii: S0261-5614(12)00284-1. doi:
10.1016/j.clnu.2012.12.011
BACKGROUND & AIMS:
 Nasojejunal tube feeding is a standard of care in
patients with predicted severe acute pancreatitis (AP)
and several recent trials suggested that nasogastric
tube feeding (NGT) is as safe and efficient as
nasojejunal tube feeding in these patients. The aim
was to investigate whether NGT presents any benefit
to patients with mild to moderate AP.
Timing of NG feeding

51. Early NGT feeding in acute
pancreatitis...contd
METHODS:
 The study design was a randomized controlled trial. The patients
in the intervention group received NGT within 24 h of hospital
admission. The patients in the control group were on nil per os
(NPO). The severity of acute pancreatitis was determined
according to the new international multidisciplinary
classification.
CONCLUSIONS:
 NGT commenced within 24 h of hospital admission is well
tolerated in patients with mild to moderate acute
pancreatitis.
 Further, when compared with NPO, it significantly reduces
the intensity and duration of abdominal pain, need for
opiates, and risk of oral food intolerance, but not overall
hospital stay

52. Acute Pancreatitis
Issues:
 Intervention in form of ERCP

53. Timing and need for ERCP
Objectives:
 To systematically review evidence from randomized
controlled trials (RCTs) assessing the clinical effectiveness
and safety of the early routine ERCP strategy compared to
the early conservative management with or without
selective use of ERCP strategy, based on all important,
clinically relevant and standardized outcomes including
mortality, local and systemic complications as defined by
the Atlanta Classification (Bradley 1993) and by authors of
the primary study, and ERCP‐related complications in
unselected patients with acute gallstone pancreatitis

54. Selection criteria:
 RCTs comparing the early routine ERCP strategy
versus the early conservative management with or
without selective use of ERCP strategy in patients with
suspected acute gallstone pancreatitis.
 Included studies in which the population with acute
gallstone pancreatitis was a subgroup within a larger
group of patients.
 Only included studies involving only a selected
subgroup of patients with acute gallstone pancreatitis
(actual severe pancreatitis) in subgroup analyses.

55. Main results:
 Five RCTs comprising 644 participants were included in the
main analyses.
 Two additional RCTs, comprising only patients with actual
severe acute gallstone pancreatitis, were included only in
subgroup analyses.
 In unselected patients with acute gallstone pancreatitis,
there were no statistically significant differences between
the two strategies in mortality (RR 0.74, 95% CI 0.18 to
3.03), local and systemic complications as defined by the
Atlanta Classification (RR 0.86, 95% CI 0.52 to 1.43; and RR
0.59, 95% CI 0.31 to 1.11 respectively) and by authors of the
primary study (RR 0.80, 95% CI 0.51 to 1.26; and RR 0.76,
95% CI 0.53 to 1.09 respectively).

56.  Among trials that included patients with cholangitis,
the early routine ERCP strategy significantly reduced
mortality (RR 0.20, 95% CI 0.06 to 0.68), local and
systemic complications as defined by the Atlanta
Classification (RR 0.45, 95% CI 0.20 to 0.99; and RR
0.37, 95% CI 0.18 to 0.78 respectively) and by authors
of the primary study (RR 0.50, 95% CI 0.29 to 0.87;
and RR 0.41, 95% CI 0.21 to 0.82 respectively).

57.  Among trials that included patients with biliary
obstruction, the early routine ERCP strategy was
associated with a significant reduction in local
complications as defined by authors of the primary
study (RR 0.54, 95% CI 0.32 to 0.91), and a
non‐significant trend towards reduction of local and
systemic complications as defined by the Atlanta
Classification (RR 0.53, 95% CI 0.26 to 1.07; and RR
0.56, 95% CI 0.30 to 1.02 respectively) and systemic
complications as defined by authors of the primary
study (RR 0.59, 95% CI 0.35 to 1.01). ERCP
complications were infrequent

58. Authors' conclusions:
 In patients with acute gallstone pancreatitis, there is
no evidence that early routine ERCP significantly
affects mortality, and local or systemic complications
of pancreatitis, regardless of predicted severity.
 Our results, however, provide support for current
recommendations that early ERCP should be
considered in patients with co‐existing
cholangitis or biliary obstruction

59. Emergency ERCP in AP
 In persistent and severe biliary pancreatitis, when an
obstructing gallstone lodged at the ampulla of Vater

60. Acute Pancreatitis
Issue:
Surgery/Removal of sterile or infected necrosis

61. Any role of early Surgery?
 Except in the unusual situation of fulminating acute
pancreatitis with organ failure and a rapidly progressive
downhill course soon after admission to the hospital, most
patients should not undergo operation during the first
week of their illness.
 When clinical deterioration is rapid and surgery is
undertaken during the first week, these patients have a
high mortality rate.
 The outcome is better when surgery is postponed at least
until the second week or later, when the margins of the
pancreatic necrosis have become better defined, and the
acute inflammation has subsided somewhat.

62. Acute Pancreatitis
Issue: Surgery:
Background facts
 More than 80% of deaths amongst patients with acute
pancreatitis are caused by infected necrosis
 Aggressive surgical treatment required in such cases
 Patients with infected necrosis require emergent
surgery.

63. Common Organisms
 Enteric Gram Negative organisms like E.coli
 Gram positive organisms
 Anaerobes
 Fungal Infection is a late event usually following
prolonged antibiotic therapy
Daziel D J. Doolas A. “Pancreatic abscess and pancreatic necrosis: current concepts and controversies.” Problems in
General Surgery, vol 7 (3) pp 415-27. 1990

64. Diagnosis of infected necrosis
 Most reliably by CT or ultrasound-guided fine needle
aspiration (FNA) with Gram staining and culture of
the aspirate. The material should be sent for bacterial
and fungal culture.
 Some patients with infection have only a low grade
fever and a WBC <15,000. Thus, threshold must be low.
 In a minority of patients, gas bubbles are evident on
the CT study in the area of the pancreas. If this is
found, FNA is unnecessary.

65. Surgical indications in acute
pancreatitis.
Haas B, Nathens AB. Curr Opin Crit Care. 2010 Apr;16(2):153-8. doi: 10.1097/MCC.0b013e328336ae88.)
 Infected pancreatic necrosis remains the primary indication for
surgery in patients with acute pancreatitis.
 Up to a quarter of patients with acute pancreatitis develop early
bacteremia and pneumonia, and assessment of patients for
surgery should include a thorough search for nonpancreatic
sources of infection.
 Retroperitoneal, percutaneous and endoscopic approaches to
pancreatic debridement can be used with success in
appropriately selected critically ill patients.
 All minimally invasive approaches to necrosectomy are evolving,
and there is currently insufficient evidence to advocate one
approach over another.
 Management of patients with acute pancreatitis at high-volume
centers appears to be associated with a survival benefit.

66. Role of open necrosectomy in the current
management of Acute Necrotizing
Pancreatitis: A Review Article
K. Vasiliadis, C. Papavasiliou, A.Al Nimer, N. Lamprou, C. Makridis. ISRN Surg. 2013;2013:579435. doi: 10.1155/2013/579435.
Epub 2013 Jan 28
Contraindications for open necrosectomy [14, 17].
 Pancreatic and/or peripancreatic necrosis without evidence of
infection or clinical deterioration
 Early operation (within 1 week from onset of acute pancreatitis)

67. Role of Open... (Vasiliadis contd)
Indications and timing for open
necrosectomy [14, 17].
 The operation should be undertaken as late as possible, when
necroses have been ceased, viable and nonviable tissues are well
demarcated, and infected necrotic tissues are “walled off”.
 Pancreatic and/or peripancreatic necrosis complicated by
documented infection (guided FNA culture or extraluminal
retroperitoneal gas)
 Sterile necrosis: (a) Progressive clinical deterioration despite
maximal medical treatment (b) “Fulminant acute
pancreatitis”
 Massive hemorrhage or hollow viscus perforation

68. Surgery in Acute Pancreatitis: Indications
other than Infected Necrosis.
1. When the patient's condition deteriorates, often with
the failure of one or more organ systems even in
sterile necrosis
2. To drain a pancreatic abscess, if percutaneous
drainage does not produce the desired result.

69. Cholecystectomy in Gall Stone
Pancreatitis

70. Timing of cholecystectomy after mild
biliary pancreatitis: a systematic review.
van Baal MC, Besselink MG, Bakker OJ, van Santvoort HC, Schaapherder AF, Nieuwenhuijs VB,
Gooszen HG, van Ramshorst B, Boerma D; Dutch Pancreatitis Study Group. Ann Surg. 2012 May;255(5):860-
6. doi: 10.1097/SLA.0b013e3182507646.
 Interval cholecystectomy (40 days) after mild biliary
pancreatitis is associated with a high risk of
readmission for recurrent biliary events, especially
recurrent biliary pancreatitis. Cholecystectomy during
index admission for mild biliary pancreatitis appears
safe, but selection bias could not be excluded.

71. Timing of cholecystectomy after mild biliary pancreatitis.
Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG, Bollen TL, Gooszen HG, Schaapherder AF;
Dutch Pancreatitis Study Group. Br J Surg. 2011 Oct;98(10):1446-54. doi: 10.1002/bjs.7587. Epub 2011 Jun 27
 Between 2004 and 2007, patients with acute pancreatitis
were registered prospectively in 15 Dutch hospitals.
Patients with mild biliary pancreatitis were candidates for
cholecystectomy. Recurrent biliary events requiring
admission before and after cholecystectomy, and after
endoscopic sphincterotomy (ES), were evaluated.
 CONCLUSION: A delay in cholecystectomy after mild
biliary pancreatitis carries a substantial risk of recurrent
biliary events. ES reduces the risk of recurrent pancreatitis
but not of other biliary events
.

72. Cholecystectomy in Gall Stone
Pancreatitis
 In mild gallstone-associated acute pancreatitis,
cholecystectomy should be performed as soon as the
patient has recovered and ideally during the same
hospital admission.
 In severe gallstone-associated acute pancreatitis,
cholecystectomy should be delayed until there is
sufficient resolution of the inflammatory response and
clinical recovery.

73. Summary: Surgery in Acute
Pancreatitis
Büchler MW, Gloor B, Müller CA et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg
2000;232:619–626. | Article | PubMed | ISI | ChemPort |
Lytras D, Manes K, Triantopoulou C et al. Persistent early organ failure: defining the high-risk group of patients with severe acute
pancreatitis? Pancreas 2008;36:249–254. | Article | PubMed
Le Mée J, Paye F, Sauvanet A et al. Incidence and reversibility of organ failure in the course of sterile or infected necrotizing
pancreatitis. Arch Surg 2001;136:1386–1390. | Article | PubMed

74. Summary
 Mild acute pancreatitis is not an indication for
pancreatic surgery.
 Infected pancreatic necrosis in patients with
clinical signs and symptoms of sepsis is an
indication for intervention including surgery and
radiological drainage.

75. Summary
 Patients with sterile pancreatic necrosis should be managed
conservatively and only undergo intervention in selected cases.
 Minimally invasive approach to necrosectomy is expected to
play a significant role in a selected group of patients
 Surgical and other forms of interventional management should
favor an organ-preserving approach, which involves debridement
or necrosectomy combined with a postoperative management
concept that maximizes postoperative evacuation of
retroperitoneal debris and exudate.
 Cholecystectomy should be performed to avoid recurrence of
gallstone-associated acute pancreatitis.
 ES is alternative to cholecystectomy but there is a theoretical risk
of introducing infection into sterile pancreatic necrosis.

76. Acute Pancreatitis Revisited
Thanks
Dr Arth Shah Dr Manoj K Ghoda

79. SAP
 SAP is defined by the Atlanta classification as an AP
with local and/or systemic complications[Bradley EL 3rd. A
clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis,
Atlanta, Ga, September 11 through 13, 1992. Arch Surg. 1993;128:586–590.].
 Some patients develop pancreatitis-associated organ
failure during the early phase of the SAP [Stanten R, Frey CF.
Comprehensive management of acute necrotizing pancreatitis and pancreatic abscess. Arch Surg. 1990;125:1269–1274;
discussion 1274-1275.].

80. Severe Acute Pancreatitis
Clinical features and Diagnosis
and
Its Interpretation

81. Diagnosis of Severity
“C” reactive Protein:
 Together with both amylase and lipase, often
provides a precise picture of the clinical situation
(Del Prete M et al.)
 C-reactive protein (cut-off of 150 mg/L) is a useful
indicator of necrosis with a sensitivity and
specificity of 80%
 It is required to be measured more than 48 h after the
onset of symptoms [Dervenis C, Johnson CD, Bassi C, Bradley E, Imrie CW, McMahon MJ,
Modlin I. Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus
conference. Int J Pancreatol. 1999;25:195–210. ].

82. Diagnosis of Severity
 Urinary trypsinogen activation peptide
(TAP),
 Serum and urinary trypsinogen [Hirano T, Manabe T. A
possible mechanism for gallstone pancreatitis: repeated short-term pancreaticobiliary duct obstruction with exocrine
stimulation in rats. Proc Soc Exp Biol Med. 1993;202:246–252., Lempinen M, Stenman UH, Finne P, Puolakkainen P, Haapiainen
R, Kemppainen E. Trypsinogen-2 and trypsinogen activation peptide (TAP) in urine of patients with acute pancreatitis. J Surg
Res. 2003;111:267–273. ],
 But these are less widely available.

83. Diagnosis of Severity
 Urinary trypsinogen-2 is comparable diagnostic
accuracy, and provides greater (99%) negative
predictive value.
 The novel serum markers procalcitonin and
interleukin 6 allow earlier prediction (12 to 24 hours
after admission) of severity. [Papachristou GI, Papachristou DJ, Avula H, Slivka A,
Whitcomb DC. Obesity increases the severity of acute pancreatitis: performance of APACHE-O score and correlation
with the inflammatory response. Pancreatology. 2006;6:279–285.],
 Serum interleukins-6 and -8 and polymorphonuclear
elastase at 24 h after admission. [Rau BM. Predicting severity of acute pancreatitis.
Curr Gastroenterol Rep. 2007;9:107–115. ].

84. Other tests
 61-80 % of patients show leukocytosis with
shift to the left.
 54-82 % lymphopenia is noted.
 Anemia
 S. Bil, Urea, SGOT,LDH, Sugar, Calcium,
and ABG abnormal
 Daily urine examination is helpful. In urine
the proteinuria, a microhematuria, and
casts may be seen.

85. Sequential organ failure assessment score
(SOFA) .
Organ system
involved
Score
1 2 3 4 5
Cardiovascular No hypotension MAP < 70 mmHg
Dopamine or
dobutamine (any
dose)
Dopamine > 5
μg/kg per min or
adrenaline
(epinephrine) < 0.1
μg/kg per min or
noradrenaline
(norepinephrine) <
0.1 μg/kg per min
Dopamine < 0.1
μg/kg per min or >
15 μg/kg per min or
adrenaline > 0.1
μg/kg per min or
noradrenaline > 0.1
μg/kg per min
Respiratory
PaO2/FiO2
(mmHg)
> 400 400-300 300-200 200-1001 ≤ 1001
Renal creatinine
(μmol/L)
< 100 100-200 200-350 350-500 > 500
Neurological
glasgow coma
score
15 14-13 12-10 9-7 ≤ 6
Haematological
platelet count (×
109/L)
> 150 150-100 100-50 20-50 ≤ 20
Hepatic bilirubin
(μmol/L)
< 20 20-60 60-120 120-240 > 240
1SOFA: Sequential organ failure assessment, World J Gastroenterol. 2009 June 28; 15(24): 2945–2959. Published online 2009 June 28. doi: 10.3748/wjg.15.2945.

86. Modified multiple organ dysfunction
score
 Organ system involved Score 1 2 3 4 5 Cardiovascular
PAHR (beats/min) ≤ 10 10-15 30-15 20-30 > 30 Respiratory
PaO2/FiO2 (mmHg) > 300 300-225 150-225 75-150 < 75
Renal creatinine (μmol/L) < 100 100-200 200-350 350-500 >
500 Neurological glasgow coma score 15 14-13 12-10 9-7 ≤ 6
Hematological platelet count (× 109/L) > 120 80-120 50-80
20-50 ≤ 20 Hepatic bilirubin (μmol/L) < 20 20-60 60-120
120-240 > 240
 PAHR: Pressure-adjusted heart rate [heart rate × (right
atrial pressure/mean arterial pressure]; FiO2: Fraction of
inspired oxygen.
 World J Gastroenterol. 2009 June 28; 15(24): 2945–2959.
 Published online 2009 June 28. doi: 10.3748/wjg.15.2945.

87.  Since the mortality in the presence of pancreatic necrosis increases
from 1% to 10%-23%, the importance of early detection of pancreatic
necrosis is not to be overlooked [Balthazar EJ. Acute pancreatitis: assessment of severity
with clinical and CT evaluation. Radiology. 2002;223:603–613. ].
 Contrast-enhanced CT has been considered the “gold standard” for the
diagnosis of pancreatic necrosis [Ranson JH, Balthazar E, Caccavale R, Cooper M. Computed
tomography and the prediction of pancreatic abscess in acute pancreatitis. Ann Surg. 1985;201:656–665. Simchuk EJ,
Traverso LW, Nukui Y, Kozarek RA. Computed tomography severity index is a predictor of outcomes for severe
pancreatitis. Am J Surg. 2000;179:352–355. ].

88.  Therefore, immediate assessment should include clinical
evaluation particularly of any cardiovascular, respiratory
and renal compromise, BMI, chest X-ray and different
acute diseases scores.
 The presence of any single and/or multiple organ failure
has been increasingly recognized as an important variable
for predicting mortality from AP.
 The most common organ dysfunction scores used for
critically ill patients are the Multiple Organ Dysfunction
Score (MODS) and the Sequential Organ Failure
Assessment (SOFA)[Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM,
Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction/failure
in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related
problems" of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26:1793–800. Marshall JC,
Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable
descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638–1652.] (Tables 3 and 4).

89.  Although these scoring systems can help the physician
in a first assessment of the patient, the most important
distinction in terms of prediction of severity is the
presence of severe manifestations of the disease such
as evidence of SIRS and presence of organ failure.

90.  Mofidi, in a recent retrospective study of 259 patients
admitted with AP, showed that the mortality rate was
significantly higher in patients who developed or had
persistent SIRS at 48 h after admission (25.4%) than in
patients who had transient SIRS (8%) or no SIRS in the
first 48 h (0.7%)[Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic
inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg. 2006;93:738–744. .

91. Ranson’s Criteria
At admission
 > 55 years
 WCC > 16000 cells/mm3
 blood glucose > 200 mg/dL)
 serum AST > 250 IU/L
 serum LDH > 350 IU/L

92.  Acute pancreatitis graded with CT and CT severity index
table
 Grade CT finding Points Necrosis Severity index
Percentage Additional points A Normal pancreas 0 0 0 0
B Pancreatic enlargement 1 0 0 1 C Pancreatic
inflammation and/or peripancreatic fat 2 < 30 2 4 D Single
peripancreatic fluid collection 3 30-50 4 7 E Two or more
fluid collections and/or retroperitoneal air 4 > 50 6 10
 World J Gastroenterol. 2009 June 28; 15(24): 2945–2959.
 Published online 2009 June 28. doi: 10.3748/wjg.15.2945.

93.  Although CT is useful in detecting pancreatic necrosis, it is not able to
detect a super-infection of necrosis in the later stage of the disease
unless gas bubbles are seen within the necrotic area[Uhl W, Roggo A,
Kirschstein T, Anghelacopoulos SE, Gloor B, Müller CA, Malfertheiner
P, Büchler MW. Influence of contrast-enhanced computed tomography
on course and outcome in patients with acute pancreatitis. Pancreas.
2002;24:191–197. ].
 Patients with persisting organ failure, or in whom new organ failure
develops, and in those with persisting pain and signs of sepsis, will
require evaluation by dynamic contrast enhanced CT. CT evidence of
necrosis correlates well with the risk of other local and systemic
complications.
 Since pancreatic necrosis commonly remains stable in appearance, a
follow-up CT scan at 3 to 4 wk is not normally considered[Vitellas KM,
Paulson EK, Enns RA, Keogan MT, Pappas TN. Pancreatitis
complicated by gland necrosis: evolution of findings on contrast-
enhanced CT. J Comput Assist Tomogr. 1999;23:898–905. ].

94. Ranson’s Criteria
At 48 hours
 Calcium < 8.0 mg/dL)
 Hematocrit fall > 10%
 Oxygen (hypoxemia PO2 < 60 mmHg)
 BUN increased by 5 or more mg/dL) after IV fluid
hydration
 Base deficit (negative base excess) > 4 mEq/L
 Sequestration of fluids > 6 L

95. APACHE II score
 Hemorrhagic peritoneal fluid
 Obesity
 Indicators of organ failure
 Hypotension (SBP <90 mm HG) or tachycardia >
130 beat/min
 PO2 <60 mmHg
 Oliguria (<50 mL/h) or increasing BUN and
creatinine
 Calcium <8.0 mg/dL or
 Albumin <3.2.g/dL)

96. APACHE II score
 Apache score of ≥ 8 Organ failure Substantial
pancreatic necrosis (at least 30% glandular
necrosis according to contrast-enhanced CT)
 Interpretation If the score ≥ 3, severe pancreatitis
likely. If the score < 3, severe pancreatitis is
unlikely, Or
 Score 0 to 2 : 2% mortality Score 3 to 4 : 15%
mortality Score 5 to 6 : 40% mortality Score 7 to 8 :
100% mortality

97. Diagnosis
Abdominal ultrasound:
 Very popular and useful
 High positive predictive value >95%
 Moderate to high negative predictive value,
85=90%

98. Diagnosis
Computerized tomography (CT) scan.
 Positive predictive value, negative predictive value,
sensitivity and specificity as good as USG
 More useful for peripancreatic lesion and Necrosis.

99. Diagnosis
Endoscopic ultrasound (EUS):
 Excellent Mode
 Comparable or superior to both CT and USG
 Additional advantage of accurately visualizing Lower
CBD.
 Useful for outlining the treatment

100. Diagnosis
MRCP / MRI
 Comparable to CT
 Use of Gadolinium may increase sensitivity and
specificity
 No “contrast” related renal problems
 Additional advantage of visualizing Biliary tree

101. Diagnosis
ERCP:
 ERCP is usually used only in the presence of gallstones.
 The benefits of ERCP with sphincterotomy (ES) has been studied in 3 randomized
trials[Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of
urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus
conservative treatment for acute pancreatitis due to gallstones. Lancet. 1988;2:979–983] and 2 meta-
analyses[Petrov MS, van Santvoort HC, Besselink MG, van der Heijden GJ, van Erpecum KJ, Gooszen
HG. Early endoscopic retrograde cholangiopancreatography versus conservative management in
acute biliary pancreatitis without cholangitis: a meta-analysis of randomized trials. Ann Surg.
2008;247:250–257.]. Patients with predicted mild acute biliary pancreatitis (ABP) in the absence of
cholangitis have not shown benefits from an early ERCP.
 The decision on management of patients with predicted severe ABP is still debatable. The most
recent United Kingdom guidelines recommend that urgent therapeutic ERCP should be performed
within 72 h of admission in all patients with predicted severe ABP, whether or not cholangitis is
present[UK guidelines for the management of acute pancreatitis. Gut. 2005;54 Suppl 3:iii1–iii9.].
 However, a recent meta-analysis by Petrov et al[Petrov MS, van Santvoort HC, Besselink MG, van der
Heijden GJ, van Erpecum KJ, Gooszen HG. Early endoscopic retrograde cholangiopancreatography
versus conservative management in acute biliary pancreatitis without cholangitis: a meta-analysis of
randomized trials. Ann Surg. 2008;247:250–257. ] demonstrated that early ERCP with or without ES
had no beneficial effect in patients with predicted mild or severe ABP without cholangitis. The
conclusion of this study was partially supported by the 2007 guidelines of the American
Gastroenterology Association which stated that early ERCP in patient with severe ABP without signs
of acute cholangitis is still not uniformly accepted in the literature[Forsmark CE, Baillie J. AGA
Institute technical review on acute pancreatitis. Gastroenterology. 2007;132:2022–2044. ].

102. Diagnosis of Various Forms of
disease
 The acute interstitial pancreatitis is characterized by
rapidity, a relative short duration of disease.
 Clinical features usually disappear during 3-7, and
acute pathological changes by 10-14 days.
 In most mild cases at an early stage, few of abnormal
signs of disease are observed.
 Pain and vomiting are and quickly pass under the
influence of conservative treatment,
 The systemic involvement is minimal and metabolic
abnormalities are very few.

104. Acute necrotizing pancreatitis
 Clinical implications of necrosis last for more than 3 4
weeks, and pathological changes may last from 1- 5
months.
 Anemia, moderate to severe abdominal pain and
repeated vomiting are usually present.
 The patient may go in to shock.
 Vigorous resuscitative measures are mandatory in
these cases.

105.  Aseptic reactive process involve not only a gland and a
retroperitoneal fat, but also surrounding organs.
 The most important objective sign is palpated in region glands
the infiltrate arising for 5-7th day and later from the beginning of
an attack.
 This conglomerate is not very painful, has no accurate borders
and becomes more expressed at a premise under a back of the
patient of a pillow or the platen.
 The condition of the patient more often moderately severe,
becomes perceptible the appetite depression, moderately
expressed pallor of integuments, is frequent - a paresis
GASTROINTESTINAL TRACT.
 Temperature, as a rule, afebrile, the leukocytosis with
neutrophilic alteration is moderately expressed. Indicators of an
ESR, the S-jet protein, a fibrinogen are raised.

106.  Clinical Classifications
 Depending on a phase of development of pathological
process it is possible to delineate 4 forms of an acute
pancreatitis:
 acute interstitial, corresponding to an edema phase
 acute necrotic, expressing a phase of formation of a
necrosis
 infiltrative-necrotizing
 it is purulent-necrotizing, corresponding to a phase of
fusion and a sequestration of the necrotic locuses.

108.  Pancreas, liver, and kidney functions (including levels of pancreatic enzymes amylase and lipase)
 Signs of infections
 Blood cell counts indicating signs of anemia
 Pregnancy test
 Blood sugar, electrolyte levels (an imbalance suggests dehydration) and calcium level
 Results of the blood tests may be inconclusive if the pancreas is still making digestive enzymes and
insulin.
 Diagnostic imaging tests are usually needed to look for complications of pancreatitis, including
gallstones.
 Diagnostic imaging tests may include the following:
 X-ray films may be ordered to look for complications of pancreatitis as well as for other causes of
discomfort.

109. Chinese herbal medicine in AP
 Authors' conclusions: Some Chinese medicinal
herbs may work in acute pancreatitis. However,
because the trials were of low quality, the evidence is
too weak to recommend any single herb. Rigorously
designed, randomized, double‐blind,
placebo‐controlled trials are required.