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5 to 40 per 100,000 with overall mortality of 1.5 per 100,000; severe forms, however, can have a mortality >30%.

  • Alcohol (men)
  • Biliary (women): ultrasound, endoscopic ultrasound (before ERCP)
  • Trauma (abdominal, surgical, post-ERCP)
  • Metabolic (hypertriglyceridemia, uremia, hypothermia, hypercalcemia)
  • Infections (EBV, mumps, HIV, HBV, mycoplasma, Campylobacter, Legionella)
  • Drugs (steroids, sulfonamides, azathioprine, NSAIDs, diuretics, didanosine, etc.)
  • Autoimmune (PAN, SLE, TTP)
  • Toxins (methanol, organophosphates, scorpion venom)
  • Pancreatic tumors
  • Idiopathic

Inappropriate activation of trypsin leads to activation of protease activated receptor-2 (PAR2) and activation of other pancreatic enzymes. It results in out of proportion inflammation of pancreas leading to a SIRS-like response.

Abdominal pain + lipase >3 times normal is sufficient for diagnosis.

Negative type-2 trypsinogen in urine (stick) virtually eliminates Dx of pancreatitis.

  • Clinical features:
    • Abdominal pain typically radiating to the back
    • Nausea, vomiting
    • Abdominal distension
    • Jaundice
    • Fever
    • Tachycardia
    • Hypotension
    • Cullen's sign (hemorrhagic discoloration of the umbilicus)
    • Grey-Turner's sign (hemorrhagic discoloration of the flanks)
  • Laboratory findings:
    • Increased serum amylase >3 times upper limit of normal (returns to normal in 2–4 days)
    • Increased serum lipase (more sensitive and specific, remains elevated 10–14 days)
    • Increased CRP (more frequent association with pancreatic necrosis, 24- to 48-hour latency period)
    • IL-6, procalcitonin, and polymorphonuclear elastase could be used
  • Radiologic findings:
    • X-ray: duodenal ileus, sentinel loop sign, colon cutoff sign, pleural effusion (especially left side)
    • Ultrasonography: more sensitive to identify gallstones, biliary ducts. Difficult to assess pancreas. Endoscopic ultrasound of use when other modalities fail or cannot be used to assess biliary disease and guide therapy
    • CT scan: contrast-enhanced CT gold standard to diagnose pancreatitis. Useful to assess necrosis, abscess, fluid collections, hemorrhage. Indicated if dilemma in diagnosis/complications. Recommended to delay until 48–72 hours or repeat at this time if initial obtained on presentation. Not of much use if disease mild. Carries risk of contrast nephropathy
    • MRI: useful when CT contraindicated

  • Pancreatitis deemed severe if local complications (necrosis, abscess, pseudocyst) or organ failure
  • Multiple classifications and criteria are available to assess severity
  • Ranson's criteria (Table 215-1) have the disadvantage of requiring 48 hours to assess and cannot help at-risk patients in initial assessment
  • The 2004 International Consensus Guidelines to assess severe acute pancreatitis on presentation (Table 215-2) are also helpful
  • Balthazar's classification (Table 215-3) assesses pancreatic necrosis based on CT criteria

Table 215-1 Ranson's Criteria
Table 215-2 Risk Factors for Severe Acute Pancreatitis

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