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World Journal of
Clinical Cases
World J Clinical Cases 2019 May 6; 7(9): 1006-1092
ISSN 2307-8960 (online)
Published by Baishideng Publishing Group Inc
W J C C World Journal of
Clinical Cases
Contents Semimonthly Volume 7 Number 9 May 6, 2019
REVIEW
1006 Evaluation and management of acute pancreatitis
Chatila AT, Bilal M, Guturu P
ORIGINAL ARTICLE
Retrospective Cohort Study
1021 Rituximab-induced IgG hypogammaglobulinemia in children with nephrotic syndrome and normal pre-
treatment IgG values
Marzuillo P, Guarino S, Esposito T, Di Sessa A, Orsini SI, Capalbo D, Miraglia del Giudice E, La Manna A
Retrospective Study
1028 Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde
cholangiopancreatography: A large sample sized retrospective study
Deng F, Zhou M, Liu PP, Hong JB, Li GH, Zhou XJ, Chen YX
CASE REPORT
1038 Laparoscopic appendectomy for elemental mercury sequestration in the appendix: A case report
Norčič G, Čebron Ž, Sever P, Grosek J, Tomažič A
1043 Sofosbuvir/Ribavirin therapy for patients experiencing failure of ombitasvir/paritaprevir/ritonavir +
ribavirin therapy: Two cases report and review of literature
Sato K, Yamazaki Y, Kobayashi T, Takakusagi S, Horiguchi N, Kakizaki S, Andou M, Matsuda Y, Uraoka T, Ohnishi H,
Okamoto H
1053 Management of the late effects of disconnected pancreatic duct syndrome: A case report
Yamada R, Umeda Y, Shiono Y, Okuse H, Kuroda N, Tsuboi J, Inoue H, Hamada Y, Tanaka K, Horiki N, Takei Y
1060 Nerve coblation for treatment of trigeminal neuralgia: A case report
Yang XH, Li Y, Yang LQ, Wu BS, Ni JX
1066 Adult-onset mitochondrial encephalopathy in association with the MT-ND3 T10158C mutation exhibits
unique characteristics: A case report
Fu XL, Zhou XX, Shi Z, Zheng WC
1073 Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and
treated by endoscopic retrograde cholangiopancreatography: A case report
Cui GX, Huang HT, Yang JF, Zhang XF
WJCC https://www.wjgnet.com
May 6, 2019 Volume 7 Issue 9
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Contents World Journal of Clinical Cases
Volume 7 Number 9 May 6, 2019
1080 Crizotinib-induced acute fatal liver failure in an Asian ALK-positive lung adenocarcinoma patient with liver
metastasis: A case report
Zhang Y, Xu YY, Chen Y, Li JN, Wang Y
1087 Coexistence of breakpoint cluster region-Abelson1 rearrangement and Janus kinase 2 V617F mutation in
chronic myeloid leukemia: A case report
Shi XB, Jiang JF, Jin FX, Cheng W
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Contents World Journal of Clinical Cases
Volume 7 Number 9 May 6, 2019
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Submit a Manuscript: https://www.f6publishing.com World J Clinical Cases 2019 May 6; 7(9): 1006-1020
DOI: 10.12998/wjcc.v7.i9.1006 ISSN 2307-8960 (online)
REVIEW
Evaluation and management of acute pancreatitis
Ahmed T Chatila, Mohammad Bilal, Praveen Guturu
ORCID number: Ahmed T Chatila
(0000-0003-4089-8823); Mohammad
Bilal (0000-0002-1784-212X);
Praveen Guturu
(0000-0001-6887-9080).
Author contributions: Bilal M and
Guturu P were involved in concept
design. Chatila AT, Bilal M and
Guturu P wrote critical portions of
the manuscript. Guturu P edited
the manuscript and provided
expert opinion.
Conflict-of-interest statement: The
authors report no conflict of
interest and have no financial
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manuscript.
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ses/by-nc/4.0/
Manuscript source: Invited
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Received: January 16, 2019
Peer-review started: January 17,
2019
First decision: March 10, 2019
Revised: March 19, 2018
Accepted: March 26, 2019
Article in press: March 26, 2019
Published online: May 6, 2019
Ahmed T Chatila, Department of Internal Medicine, The University of Texas Medical Branch,
Galveston, TX 77555, United States
Mohammad Bilal, Division of Gastroenterology and Hepatology, The University of Texas
Medical Branch, Galveston, TX 77555, United States
Praveen Guturu, Division of Gastroenterology and Hepatology, the University of Texas
Medical Branch, Galveston, TX 77555, United States
Corresponding author: Mohammad Bilal, MD, Academic Fellow, Doctor, Division of
Gastroenterology and Hepatology, The University of Texas Medical Branch, 301 University
Blvd., Galveston, TX 77555, United States. mobilal@utmb.edu
Telephone: +1-412-6603624
Fax: +1-409-7723394
Abstract
Acute pancreatitis (AP) is one of the most common gastrointestinal causes for
hospi-talization in the United States. In 2015, AP accounted for approximately
390000 hospitalizations. The burden of AP is only expected to increase over time.
Despite recent advances in medicine, pancreatitis continues to be associated with
a substantial morbidity and mortality. The most common cause of AP is
gallstones, followed closely by alcohol use. The diagnosis of pancreatitis is
established with any two of three following criteria: (1) Abdominal pain
consistent with that of AP; (2) Serum amylase and/or lipase greater than three
times the upper limit of normal; and (3) Characteristics findings seen in cross-
sectional abdominal imaging. Multiple criteria and scoring systems have been
established for assessing severity of AP. The cornerstones of management include
aggressive intravenous hydration, appropriate nutrition and pain management.
Endoscopic retrograde cholangiopancreatography and surgery are important
aspects in management of acute gallstone pancreatitis. We provide a
comprehensive review of evaluation and management of AP.
Key words: Acute pancreatitis; Necrotizing pancreatitis; Resuscitation; Gallstone
pancreatitis
©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
Core tip: Acute pancreatitis (AP) is one of the most common gastrointestinal causes for
hospitalization in the United States. In 2015, AP accounted for approximately 390000
hospitalizations. The most common cause of AP is gallstones, followed closely by
alcohol use. Multiple criteria and scoring systems have been established for assessing
severity of AP. The cornerstones of management include aggressive intravenous
WJCC https://www.wjgnet.com
May 6, 2019 Volume 7 Issue 9
1006
P-Reviewer: Gencdal G, Sandblom
G
S-Editor: Dou Y
L-Editor: A
E-Editor: Wu YXJ
hydration, appropriate nutrition and pain management. Endoscopic retrograde
cholangiopancreatography and surgery are important aspects in management of acute
gallstone pancreatitis. We provide a comprehensive review of evaluation and
management of AP.
Citation: Chatila AT, Bilal M, Guturu P. Evaluation and management of acute pancreatitis.
World J Clinical Cases 2019; 7(9): 1006-1020
URL: https://www.wjgnet.com/2307-8960/full/v7/i9/1006.htm
DOI: https://dx.doi.org/10.12998/wjcc.v7.i9.1006
INTRODUCTION
Acute pancreatitis (AP) is one of the most common gastrointestinal causes for
hospitalization in the United States. In 2015, AP accounted for 390940 hospitalizations
making it one of the most frequent causes of gastrointestinal hospitalizations in the
nation with the annual incidence only expected to increase over time[1-3]. Despite
recent advances in gastroenterology, AP continues to be associated with substantial
mortality, morbidity and healthcare resource utilization[2,3].
In this report, we provide a comprehensive review of the epidemiology, patho-
physiology, evaluation, and management of AP.
EPIDEMIOLOGY
The annual incidence of AP ranges from 15.9 to 36.4 per 100000 persons. The burden
of the disease on the healthcare resource utilization is expected to increase in the near
future[2-5]. Despite the improvement we have seen in access to healthcare, imaging
modalities and interventions, AP continues to have significant morbidity and
mortality that has largely remained unchanged over time. The overall mortality rate
being 5% to 17% in severe AP, and 1.5% in mild AP[2,4,6].
The three most common causes of AP are gallstone/biliary related, alcohol related,
and idiopathic. These three causes account for the majority of cases of AP[2,7-10]. Biliary
pathology was estimated to be 28%-38% of the cases while alcohol accounted for 19%-
41% of the cases[8,9,11].
Prior reports have shown a significant relation of gender and race in regards to
etiology of AP. Overall, a markedly higher frequency of AP was seen among blacks
than whites, followed closely by Hispanics, Asians, and then American Indians.
Patients with AP due to alcohol use were significantly younger and were more likely
to be male and/or black, with blacks having the highest frequency of alcohol related
pancreatic disease[5,9,12]. Females are more likely to have biliary related pancreatitis[5,12].
The increase in incidence of AP has been mostly seen in woman ages < 35 and men
between the ages of 35 and 54[2].
ETIOLOGY
AP is the inflammation of the pancreas that is often associated with systemic infla-
mmatory response syndrome (SIRS) that may impair the function of other organs. The
etiology of AP can be readily identified in 75% to 85% of cases[8]. The American
Gastroenterological Association (AGA) provides a comprehensive guide to determine
the etiology of pancreatitis.
The evaluation should begin with a detailed history focusing on symptoms and
presentation. The investigation should focus on evaluation of any previous
documented gallstones, alcohol use, history of hypertriglyceridemia or hypercal-
cemia, family history of pancreatic diseases, prescription/non-prescription drug
history, history of trauma, and presence of autoimmune disease. On presentation to
the hospital, patients should have a serum amylase or lipase level checked along with
liver chemistries (bilirubin, aspartate aminotransferase, alanine aminotransferase, and
alkaline phosphatase), and abdominal ultrasound assessing for cholelithiasis or
choledocholithiasis. Extensive or invasive evaluation should be avoided on
presentation[10,13,14]. The most common etiologies of AP have been summarized in Table
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1.
Biliary Tract disease
Gallstone pancreatitis is the most common cause of AP and is estimated to be 28%-
38% of all cases of AP[8,9,11]. Gallstone induced pancreatitis is caused by duct obs-
truction by gallstone migration leading to temporary impaction of migrating stones at
the duodenal ampulla, increased duct pressure, and unregulated stimulation of the
digestive enzymes secreted by the pancreas[15,16]. This obstruction can be due to calculi
lodged in the duodenal ampulla, spasms, and fibrosis of the sphincter of Oddi[15,17-19].
Alcohol
Alcoholic pancreatitis is the second most frequent cause of AP and is estimated to be
19%-41% of all AP cases[9-11]. The association between alcohol abuse and pancreatitis is
poorly understood, but it is known that the majority of patients who abuse alcohol do
not develop pancreatitis[10,19]. In addition, two thirds of patient’s who present with
acute alcoholic pancreatitis already have developed an underlying chronic pancrea-
titis[20]. In about 8% of cases of AP related to alcohol, mutations in the pancreatic
secretory trypsin inhibitor gene (SPINK1) have been seen[21].
Hypertriglyceridemia
Hypertriglyceridemia induced pancreatitis is a rare cause of AP and is estimated to
make up 1%-4% of cases[22,23]. Hypertriglyceridemia induced pancreatitis is thought to
be due to the hydrolysis of excessive triglyceride rich lipoproteins releasing high
concentration of free fatty acids which injure the vascular endothelium and acinar
cells of the pancreas. This injury causes a self-perpetuating ischemic and acidic
environment with resultant toxicity[23-26]. Specific genes associated with cystic fibrosis
transmembrane conductance regular mutation and a tumor necrosis factor were
found to be risk factors for AP secondary to hypertriglyceridemia[22,27]. We recommend
checking a triglyceride level in all patients with AP in which history is not suggestive
of alcohol use and imaging does not indicate a biliary pathology.
Genetic
Several genetic mutations have been associated with the development of AP. Specific
cystic fibrosis gene (CFTR) genotypes have been shown to be significantly associated
with AP, with the highest risk seen in mild phenotypic genotypes[28]. Hereditary
pancreatitis is an autosomal dominant disease caused by cationic trypsinogen (PRSS1)
gene mutation, but is usually associated with chronic pancreatitis[29,30]. In younger
patients, with no identifiable cause of AP, genetic etiologies should be considered.
Drug
Drug induced AP is a rare entity. There should be a high level of suspicion after
common causes of AP have been ruled out. An estimated 2%-4.8% of reported cases of
AP have been related to some medications[31,32]. A wide variety of drugs have been
reported as possible causes of AP including 6-mercaptopurine, sulfonamides,
diuretics, didanosine, pentamidine, tetracycline, azathioprine, estrogen, and
steroids[33]. The proposed mechanisms of drug induced AP include immunologic
reactions, direct toxic effect, toxic metabolite, ischemia, and thrombosis[33].
Infectious
Various infections have been associated with AP including viral, bacterial, fungal, and
parasitic. Infections which have been reported to cause AP include mumps, coxsackie
virus, hepatitis B virus, cytomegalovirus, varicella-zoster virus, herpes simplex virus,
Mycoplasma, Legionella, Leptospira, Salmonella, Aspergillus, Toxoplasma, and
Cryptosporidium[34-36]. From infectious causes, viruses are the leading etiology of
AP[35].
Trauma
Any blunt trauma to the pancreas can cause AP, but this diagnosis should be made
when there is a high suspicion. The incidence of pancreatic injury comprises 0.2% to
12% of all abdominal traumas[37,38]. The majority of pancreatic trauma is related to
direct trauma with only a minority associated with blunt trauma[39].
Post-endoscopic retrograde cholangiopancreatography (ERCP)
Serum amylase elevations up to three times the upper limit of normal have been
reported after 24 h of an ERCP[40]. It has been reported in 1.3%-4.3% of ERCP pro-
cedures. The most common risk factors for post-ERCP related AP are younger age,
female gender, history of sphincter of Oddi dysfunction, pancreatic duct opacification,
cholangitis, and duodenal perforation[41-44].
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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.
Hypercalcemia
Elevated calcium levels have also been linked to AP. The mechanism behind It stems
from an exposure to high concentrations of calcium leading to toxicity, disruption of
intracellular signaling, and cell damage[45]. In addition, AP has been reported in 1.5%
of patients with hyperparathyroidism which is thought to be due to hypercalcemia[46].
Pancreatic anatomical abnormalities
Anatomical abnormalities of the pancreas including annular pancreas and pancreatic
ductal stricture are accepted rare causes of AP as well as recurrent AP. However the
role of pancreas divisum remains as an etiology of AP is controversial[9,47]. Pancreas
divisum is a common variant seen in up to 14% of patients[48-50]. The clinical implica-
tions remain controversial and currently there is no consensus if pancreatic divisum
alone can cause AP[9,47,51].
Vascular
Pancreatic ischemia secondary to rheumatological disease, ischemia secondary to
shock, and atheromatous embolization have also been reported as rare causes of
AP[52-54]. AP has been reported in numerous rheumatic diseases including systemic
lupus erythematosus, Sögren’s syndrome, scleroderma, and rheumatoid arthritis[52].
AP has also been reported as a rare but potential event within 48 h of transabdominal
angiographic procedures secondary to atheromatous embolization[53].
Pregnancy
AP has been rarely reported in pregnancy. In these cases five of them were found to
be due to gallstones while the other three were reported as idiopathic causes[55].
Malignancies
AP can present as a manifestation of underlying malignancy. Specifically in intra-
ductal papillary mucinous neoplasms (IPMNs), AP has been reported to be a
presenting symptom with AP occurring in up to 21% of patients diagnosed with
IPMNs[56].
Autoimmune pancreatitis (AIP)
AIP is a rarely identified disorder that is presumed to be autoimmune in etiology
associated with IgG4 cholangitis, salivary gland disorders, mediastinal fibrosis, and
inflammatory bowel disease. AIP should be considered in patients presenting with
AP, particularly those with previously diagnosed autoimmune disorders[57,58]. AIP is
classified into two types - Type 1 and 2. Type 1 AIP is part of a systemic IgG4 positive
disease meeting the HISORt criteria proposed by the Mayo Clinic[59]. The HISORt
criteria includes the presence of one or more of the following: diagnostic histology,
characteristic imagining on computed tomography (CT) scan, elevated serum IgG-4
levels, other organ involvement, and/or response of symptoms to glucocorticoid
therapy[59]. Type 2 AIP or idiopathic duct-centric pancreatitis is defined by granulo-
cytic lesions in the absence of IgG-4-positive cells and systemic involvement[58].
Idiopathic
Idiopathic or unidentifiable causes of pancreatitis have been reported in about 10%-
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40% of all AP cases[9,60]. Idiopathic pancreatitis is often due to microlithiasis which is
not picked up on routine abdominal imaging.
DIAGNOSIS
The revised Atlanta classification for AP helps to standardize the diagnosis of AP. The
classification system defined pancreatitis as the presence of any two of the following
three criteria being present in the patient: Abdominal pain consistent with that of AP,
serum amylase and/or lipase levels greater than three times the upper limit of
normal, and characteristics findings of AP seen in cross-sectional abdominal ima-
ging[10,13,14,61-64].
Presentation
The diagnosis of AP begins early on in a patient’s course and should be suspected in
patients presenting with clinical symptoms and features consistent with AP -
epigastric abdominal pain, nausea, vomiting, abdominal pain radiating to the back
(seen in 40%-70% of patients)[10,13,14,61,64]. This pain can last several hours to several.
Nausea has also been seen in about 90% of patients with AP which can last for several
days as well[64].
Physical exam
Pancreatitis is an inflammatory condition of the pancreas extending to local and
distant extra-pancreatic tissues[65]. Exam findings associated with AP vary greatly
based on the severity of AP. Patients with mild disease may present with little
tenderness to palpation throughout the abdomen, while patients with severe disease
may present with severe abdominal pain to palpation and absence of bowel
sounds[10,13,14].
Cullen’s and Turner signs are seen in about 3% of patient’s and are associated with
a mortality of about 37%. These signs are many times associated with hemorrhagic
pancreatitis, however neither sign is not specific to hemorrhage[66].
Laboratory tests
The evaluation of pancreatic enzymes (Lipase and Amylase) released from inflamed
tissue is the cornerstone of biochemical diagnosis of AP[10,13,14,62,63,65,67]. The Atlanta
criteria identified a serum amylase and/or serum lipase greater than three times the
upper limit of normal as a contributory factor to the diagnosis of panc-
reatitis[10,13,14,62,63,67]. Although there is no optimal diagnostic test for pancreatitis, lipase
is preferred over amylase in routine clinical practice[10].
Tyrpsinogen activation peptide is cleaved from trypsinogen to produce active
trypsin and can also be seen in AP[68]. This can be measured in both the urine and
serum. These tests are not readily available and hence not routinely used in clinical
practice.
All patients with AP should get a complete blood cell count, basic metabolic panel,
liver function tests (LFTs), coagulation profile, C-reactive protein (CRP), and total
albumin as part of their initial laboratory work-up. An arterial blood gas should be
performed in patients with hypoxia[10,13,14].
Imaging
Contrast enhanced CT scan of the abdomen and magnetic resonance imaging (MRI) of
the abdomen is the best imaging modalities for visualization of pancreatic pathology.
Although these tests are not routinely indicated in patients with mild AP. The classic
feature seen in AP is the presence of focal or diffuse enhancement of the pan-
creas[10,13,14,69].
CT scan of the abdomen is used to both diagnose pancreatitis and many times helps
establish scales of severity[69]. A non-contrast CT scan helps to establish the extent of
pancreatic and extra-pancreatic inflammation[10,13,14]. A contrast enhanced CT scan of
the abdomen is the gold standard for the establishment of severity of pan-
creatitis[10,13,14]. The CT severity index is based on a combination of peri-pancreatic
inflammation, phlegmon, and degree of pancreatic necrosis seen on initial CT scan
study and was developed to grade the severity of pancreatitis and establish the
correlated mortality[10,13,14,70]. A high CT severity index correlated with a 92% morbidity
and 17% mortality rate, while a low CT severity index correlated with a 2% morbidity
and 0% mortality rate[70]. An early CT scan of the abdomen on admission has not been
shown to affect the disease course as the CT scoring system for severity of AP is
similar to that of clinical scoring system. Thus, a CT scan of the abdomen on
admission solely to assess severity is not recommended[10,13,14,71]. It is recommended
that an ultrasound of the abdomen be obtained on all patients with AP to assess the
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Chatila AT et al. Management of AP
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presence of biliary tract obstruction from gallstones[10,13,14].
An MRI of the abdomen is indicated in patients who have elevated LFTs with
suspected common bile duct disease which cannot be visualized on ultrasound.
Otherwise, an MRI is not indicated for the diagnosis of pancreatitis[10,13,14,71].
ASSESSMENT OF SEVERITY
About 15%-20% of patient with AP will develop severe disease and will have an
elongated hospital stay with likely complications including possible death[10,13,14]. Thus,
the determination of the severity of AP is one of the most important first steps in the
management of AP. It helps in selecting appropriate treatments, ensuring proper
patient triage, initiation of applicable therapies, and stratifying patient risk for
complications. This is important because of the possibly of death related to severe AP.
Mortality rates with AP in tertiary care centers alone is reported to be between 4.8%-
9%, and when considering severe forms of the disease the mortality rates increased to
13.5%[72-74]. Several tools and scoring systems have been developed to assess the
severity of AP. These scoring systems have been summarized in Table 2. We have
reviewed the most commonly used scoring systems below:
Acute Physiology and Chronic Health Examination (APACHE) II Score
The APACHE II score was originally developed for patients in the intensive care unit
(ICU) and utilizes 12 variables in order to help calculate a score that can be used upon
admission, 24 h, and 48 h. This allows the advantage of the score being recalculated
throughout the patient’s stay allowing for appropriate adjustments and interventions.
Each of the 12 variables are translated into weights using the original APACHE score
and help to stratify a patient’s risks[75].
In comparative studies the APACHE II score was the most accurate score in predi-
cating the severity of the disease and the outcome of the disease. After 48 h, the
APACHE II score predicted the outcome in 88% of cases and outperformed both the
Ranson’s and Imrie scores[10,76]. The APACHE II score has many limitations that make
its use cumbrous. The complexity and difficulty to use, inability to distinguish
between interstitial and necrotizing pancreatitis, and poor predictive value at 24 h are
just a few of the limitations of the APACHE II score[64].
Bedside Index of Severity in Acute Pancreatitis (BISAP) Score
This score was developed in 2008 to be a mortality based prognostic tool for physi-
cians to use within the first 24 h of admission[77]. The scoring system takes into account
5 variables: Blood urea nitrogen (BUN) > 25 mg/dL, impaired mental status, SIRS, age
greater than 60, or the presence of a pleural effusion. Mortality was shown to be
greater than 20% in the highest risk group or a score of 5 and less than 1% in the
lowest group or score of 0[77]. The prognostic value of the BISAP score was found to be
similar to those of other scoring systems such as the Ranson’s, APACHE II, and
computed tomography severity index (CTSI) in determining pancreatic necrosis and
mortality[78]. The BISAP score is easy to use and authors recommend that all patients
with AP should have BISAP score calculated to assess the severity of the disease.
Glasgow criteria
This scale is also known as the Imrie score and includes 8 of the variables used in the
Ranson’s Criteria. This scale has been used in gallstone induced AP. This scale must
be determined after 48 h and uses SI units making its use difficult in the United Sta-
tes[10,13,14,79].
Ranson’s criteria
The Ranson’s criteria were one of the earliest criteria developed for assessing the
severity of AP. The score takes into account 11 variables: 5 of which are measured at
admission while 6 of these are measured 48 h after admission[10,79]. The limitation to
this scoring system is that the criteria must be taken promptly at the correct time, and
results cannot be determined until 48 h after admission. Many times the criteria are
not completely measured during the hospital stay[10]. The mortality rises with
increasing scores. Mortality was reported to be 0%-3% in patients with a score less
than 3, 11%-15% in a score greater than or equal to 3, and 40% when the score was
greater than or equal to 6[64]. The Ranson’s criteria can be cumbersome to use in
routine clinical practice at times.
Computed Tomography Severity Index
The CT severity index is based on a combination of peri-pancreatic inflammation,
phlegmon, and degree of pancreatic necrosis seen on initial CT scan of the abdomen
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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.
within one week of AP. This study was developed to grade the severity of pancreatitis
(Balthazar score) and establish a correlated mortality rate[10,13,14,70]. The presence of
necrosis on CT scan of the abdomen was a predictor of worse outcome[77,79]. In prior
studies, a high CT severity index correlated with a 92% morbidity and 17% mortality
while a low CT severity index correlated with a 2% morbidity and 0% mortality[70].
Atlanta Criteria for Severity and Revised Atlanta Classification
The Atlanta criteria was developed in 1992 and helped identify severity of AP based
on organ failure, local complications, and unfavorable prognostic signs[10,63]. The
criteria helped define specific definitions of organ failure such as shock, pulmonary
insufficiency, renal failure, and gastrointestinal bleeding. The Atlanta criteria also
helped define pancreatic complications which were the development of pseudocyst,
abscess, or parenchymal necrosis[10,63]. The Atlanta Criteria was then revised in 2012 in
an attempt to further classify the severity of AP. The revised Atlanta Classification
divides AP into interstitial edematous or necrotizing pancreatitis, distinguish early
and late phase pancreatitis, and emphasizes the importance of SIRS and multiorgan
failure[62]. Furthermore, severe AP is defined by persistent organ failure lasting greater
than 48 h[62].
Laboratory findings
There are a wide range laboratory markers that have been identified as being elevated
in AP including interleukin-B, interleukin-6, CRP, procalcitonin, antithrombin III,
substance P. However, only two of these markers have been used regularly including
C-reactive protein and hematocrit[10]. Seventh day CRP concentration was shown to
have similar accuracy to both Ranson’s and Glasgow criteria. This is a quick and
simple test that can be performed to help aid in assessing severity[80]. AP results in
third spacing increasing the hematocrit, which has been shown as an early marker for
organ failure and necrotizing pancreatitis[81].
In conclusion, no one system or criteria exists to precisely predict prognosis of AP
on admission. However, the use of clinical judgment, appropriate laboratory values,
BISAP and the APACHE II scoring systems serve as an important guide for the triage,
management and prognostication in patients with AP. CT scan of the abdomen after
72 h can help provide additional information about the severity of disease[10,13,14,71].
Both the American College of Gastroenterology and International Association of
Pancreatology/American Pancreatic Associations suggest the following as predictors
of disease severity: advanced age, any comorbid disease, body mass Index greater
than 30, presence of pleural effusion, rising hematocrit, hematocrit > 44, BUN > 20,
elevated creatinine, SIRS score > 1, and persistent organ failure[13,82].
MANAGEMENT
The cornerstones in the management of AP include aggressive early intravenous
hydration, appropriate nutrition, necessary interventions, and pain management.
Below we review the current and most up to date treatment options in AP.
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Initial assessment and triage
A crucial early step in the management of patients with AP is the initial assessment
and triage to the appropriate hospital setting. This should be addressed early within
the hospitalization to allow for appropriate management. Recent guidelines from the
AGA recommend that patients with organ failure and/or severe inflammatory
response syndrome (SIRS) should be admitted directly to the ICU[13]. The BISAP
scoring system in particular is very useful with initial assessment of AP patients with
a score of greater than or equal to three being an appropriate score to identify a
patient with a high risk of mortality and hence should undergo evaluation for ICU
admission[83]. However, we recommend that patients should be assessed on a case by
case basis.
Fluid resuscitation
The current guidelines regarding fluid resuscitation in the management of AP are
evolving. Despite these changes, there continues to be consensus in the importance
and need for aggressive early fluid resuscitation[10,13,14,84]. Early goal directed fluid
resuscitation has been shown to reduce mortality in patients with severe sepsis[85].
However, the administration of excessive fluid has been shown to have worse
outcomes after 24 h[86]. We suggest that the need of aggressive fluid resuscitation
should be evaluated after 6 and 24 h of admission and rate of fluids should be ad-
justed based on changes in mean arterial pressure, urine output, changes in BUN and
respiratory status. Two recent articles showed the importance of aggressive
intravenous fluids in hastening clinical improvement in patients with AP, as well
large volume fluid resuscitation in severe AP within the first 24 h is associated with
decreased mortality[87,88].
The choice of fluids for patients with AP has been a topic of great debate in recent
years. Prior guidelines suggested that Ringer’s Lactate was superior to Normal Saline
and should be used as the initial fluid therapy in patients with AP, with one ran-
domized trial showing Ringer’s Lactate reduced the incidence of systemic
inflammation in comparison to Normal Saline[10,89]. However, the more recent
guidelines from the AGA suggest that Normal Saline and Ringer’s Lactate are equally
efficacious in the management of AP. This is based on poor quality of evidence behind
prior studies and not focusing on important clinical outcome such as organ failure,
pancreatic necrosis or mortality[84,90]. The guidelines do state against the use of
hydroxyethyl starch (HES) fluids, since the literature has showed no differences in
mortality when comparing fluids with and without HES[84,91,92].
Nutrition
The paradigm of nutrition in AP has shifted to early initiation of nutritional supp-
lementation as compared to the conventional nil per oral strategies used in the past.
The AGA now recommends initiating early oral feedings (within 24 h) in patients
with mild AP. There was no type of diet that was specified in these recommendations,
but it is thought that beginning early feedings helps to protect the gut-mucosal barrier
and reduce bacterial translocation, which in return will reduce the risk of worse
outcomes associated with AP. These findings were based on the results of 11
randomized control trials which examined early vs delayed feeding. Although enteral
tube feeding was started within 24 h in some of these studies, no study reported the
initiation of oral feeding within 24 h. Thus, whether the 24-h time-frame is
appropriate for the oral intake of food is still unclear and will need to be studied
further[10,13,14,84,93,94].
In patients who are unable to eat, enteral feeding should be considered early
through nasogastric/nasojejunal routes as opposed to total parenteral nu-
trition[10,13,64,82,84]. There has been no difference in outcomes when compared with
nasogastric vs nasojejunual feeds.
Pain management
Pain management remains essential in the management of AP. Uncontrolled pain can
lead to hemodynamic instability leading to worse outcomes. Opioids remain the first
line choice of pain medication in AP. Recent studies showed no differences in the risk
of complications related to pancreatitis or adverse events when comparing different
opioids and routes of administration[95].
Role of antibiotics
There is no role for prophylactic antibiotics in patients with AP. Recent studies have
shown no association between the initiation antibiotic therapy in AP and severe
outcomes such as organ failure, necrosis or mortality[13,84,96].
Antibiotics do however play a large role in patients with infected pancreatitis.
Infected necrosis should considered in patient’s failing to improve after one week.
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This should be assessed promptly with acquisition of a CT scan guidance fine-needle
aspiration for gram stain or presence of gas on CT scan[13,82,97]. In these patients,
empiric treatment should be effective against common pathogens including:
Escherichia coli, Bacteroides species, Enterobacter species, Klebsiella species,
Streptococcus faecalis, Staphylococcus epidermidis and Staphylococcus aureus[14,97].
Appropriate antibiotic choices include carbapenems, quinolones, and metronidazole
which are all known to penetrate pancreatic necrosis and target these bacteria. The
routine use of antifungals is not recommended in these patients[13]. Antibiotics should
be initiated early in patients who have infected pancreatitis and may help prevent the
need for surgical necrosectomy. Delaying intervention may result in poor outcomes
for these patients[98-100].
Endoscopy
Endoscopic intervention is indicated in patients with AP who have concurrent
cholangitis or biliary obstruction. In a small subgroup of patients, persistent
choledocholithiasis can become obstructive and can lead to pancreatic/biliary tree
obstruction. This will eventually lead to severe AP that can be complicated with
cholangitis[13]. Guidelines recommend patients who have cholangitis should undergo
ERCP within twenty four hours of admission[10,13,14]. Prior reports have shown that
patients undergoing ERCP within 24 h vs patients with conservative management had
fewer complications[101]. In addition, patients with AP complicated with cholangitis or
biliary sepsis who receive early ERCP have been shown to have lower morbidity and
mortality rates[102].
However, timing of ERCP in patients with biliary pancreatitis continued to be
controversial. Recent studies have shown that urgent ERCP in patient’s having acute
biliary pancreatitis without cholangitis had no impact on clinical outcomes such as
mortality, pancreatitic infections, and organ failure[84,96].
Surgery
Indications for surgical intervention include the presence of gallstones in the
gallbladder or biliary tree, infected necrosis preferably for more than 4 wk after
antibiotics if stable, and necrosectomy in symptomatic patients [13,84].
All patients with mild AP related to gallstones should undergo cholecystectomy
during the same admission prior to discharge. Early surgical intervention in biliary
pancreatitis drastically reduces mortality and gallstones related complications[103]. In
addition, patients with moderately severe and severe AP should undergo an interval
cholecystectomy after discharge[104]. Overall, cholecystectomy in patients with
gallstone related pancreatitis have been shown to drastically reduce the incidence of
recurrent AP[9].
Patients who are asymptomatic with findings of pseudocysts and/or necrosis of the
pancreas or extrapancreatic tissue do not require surgical intervention[105]. While
historically the treatment for pancreatic necrosis was surgical intervention, most
recent guidelines point away from immediate surgical intervention[10,13,14]. Current
guidelines recommend postponing necrosectomy for four weeks in patients who are
stable[10,13,14]. This delay in surgery was shown to be associated with a decreased
mortality from 39% to 12% in patients with severe AP[106]. However, in symptomatic
patients with infected necrosis, necrosectomy is still recommended with minimally
invasive methods such as endoscopic necrosectomy as compared to surgery[10,13,14].
Alcohol cessation
All patients admitted with AP should undergo counselling for alcohol cessation[84]. A
single randomized controlled trial showed that alcohol cessation counseling at the
time of AP leads to decreased incidence of recurrent AP over a 2-year period[107]. We
suggest that all patients admitted with AP should be provided with resources to assist
with cessation of alcohol use on discharge from the hospital.
COMPLICATIONS
Local complications
The most common complications following AP include acute peri-pancreatic fluid
collection, pancreatic pseudocyst, acute necrotic collections, and walled off
necrosis[10,13,14,62]. The complications of AP have been outlined in Table 3.
Interstitial edematous pancreatitis: Interstitial edematous pancreatitis is an acute
inflammation of the pancreatic parenchyma and peri-pancreatic tissues. However,
this does not have any signs of recognizable tissue necrosis. On contrast enhanced CT
scan, enhancement of the pancreatic parenchyma with no signs of necrosis is
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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
seen[10,13,14,62].
Necrotizing pancreatitis: Necrotizing pancreatitis commonly manifests as necrosis
encompassing pancreatic parenchymal and/or peripancreatic tissues. On imaging,
these findings manifest either as an acute necrotic collection lacking a definable wall
containing variable amounts of fluid, or walled off necrosis containing a well-defined
encapsulated collection of pancreatic parenchymal and/or peripancreatic tissues.
These findings are initially sterile and may eventually become infected[10,13,14,62].
Acute peripancreatic fluid collection (APFC): APFC are homogenous collections of
fluids with no distinct inflammatory walls outside the pancreas containing minimal to
no necrosis. APFC often occurs within the first four weeks after the initial onset of
interstitial edematous pancrea-titis. On contrast enhanced CT scan, APFC is
visualized as a homogenous collection with fluid that is confined by normal fascial
planes adjacent to the pancreas[10,13,14,62].
Pancreatic pseudocyst: Pancreatic pseudocysts are collections of fluids that contain
distinct inflammatory walls outside the pancreas containing minimal to no necrosis.
This often occurs four weeks after the initial onset of interstitial edematous
pancreatitis. Contrast enhanced CT scan criteria include a clear homogenous fluid
density with well-defined borders that is encapsulated[10,13,14,62].
Acute necrotic collection: An acute necrotic collection is a collection of both fluid and
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necrosis associated with necrotizing pancreatitis. This involves either the pancreatic
and/or peripancreatic tissue. Contrast enhanced CT scan shows an intra-pancreatic or
extra-pancreatic heterogenous non-liquid density of varying degrees with no definite
wall[10,13,14,62].
Walled-off necrosis: Walled off necrosis is defined as an encapsulated collection of
pancreatic or peri-pancreatic necrosis that has formed a distinct inflammatory wall.
This occurs greater than four weeks after the initial onset of necrotizing pancreatitis.
Contrast enhanced CT scan of the abdomen shows a heterogenous liquid/non-liquid
density with varying loculations. The structure has a well demarcated wall that is
entirely encapsulated[10,13,14,62].
Hemorrhagic pancreatitis: Although rare, hemorrhagic complications can be seen and
are considered late sequelae of AP. Hemorrhage may develop secondary to ruptured
or leaking pseudoaneurysms, bleeding associated in pancreatic necrosis, and
hemorrhagic pseudocysts. Early detection of this complication is important and
surgical embolization or intervention has been shown to decrease mortality[108].
Peripancreatic complications
Peripancreatic complications encompass a number of complications. An uncommon
complication of AP includes thrombosis of the splanchnic venous circulation. This
predominantly occurs in the splenic vein but can occur in the portal and/or superior
mesenteric veins. This manifestation is seen in up to 24% of patients with AP[109]. This
can also lead to development of gastric varices leading to gastrointestinal bleeding.
Another rare but serious complication that may occur in AP includes a pseudoa-
neurysm. This should be suspected when patients develop sudden gastrointestinal
bleeding, drop in hemoglobin and worsening abdominal pain[62,82]. CT scan can often
show signs of hemorrhagic pancreatitis. These patients benefit from angio-
embolization which is often performed by interventional radiology and surgical
intervention is reserved as the last resort.
Patients with AP are also at increased risk for abdominal compartment syndrome
secondary to tissue edema from aggressive fluid resuscitation, peripancreatic
inflammation, and ascites[110].
Systemic complications
Any patient with AP is at an increased risk for exacerbation of underlying conditions
including cardiac, lung, hepatic, and nephrogenic disease. These complications should
be treated as they arise[10,14,62,82]. We suggest that patients with AP who develop serious
systemic complications should be managed in the ICU with the assistance of other
colleagues including pulmonologists, cardiologists and nephrologist.
CONCLUSION
AP continues to be a common reason for hospitalization. The most common etiologies
include gallstones, followed by alcohol. It has significant impact on healthcare
resource utilization, morbidity and mortality. Disease can vary from mild disease to
severe disease with systemic complications. The cornerstones to management include
aggressive early fluid resuscitation, appropriate nutritional supplementation and
management of complications. Patients with mild acute gallstone related pancreatitis
should undergo cholecystectomy prior to discharge to prevent recurrent episodes.
Severe AP and pancreatitis with local and systemic complications should be managed
in a multidisciplinary approach with involvement of internists, gastroenterologists,
hepatobiliary surgeons and interventional radiologists.
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