Acute necrotizing pancreatitis
Acute pancreatitis (AP) is an inflammatory condition of the pancreas that results from inappropriate intrapancreatic activation of enzymes like trypsin with downstream activation of other proenzymes into the interstitial space (rather than the acinar lumen) that causes the autodigestion of the pancreatic parenchyma, fat tissue and damages elastic fibres of blood vessels along with a marked inflammatory response.
The above picture refers to the case of a 33-year-old male, known alcohol abuser, presented with sudden onset acute epigastric pain over the last six hours. His laboratory investigations revealed serum lipase level of 3412 U/L (RR:73-393IU/L); serum amylase level of 358 IU/L(RR: 85-115IU/L), serum calcium of 6.1 mg/dl (RR:8.5-10mg/dl), blood urea of 66mg/dL (RR;10-50mg/dl) and creatinine of 2.5mg/dL (RR;0.8-1.0mg/dl). The abdominal computed tomography revealed features of acute pancreatitis with the Revised Atlanta Classification score of 8/10. Despite aggressive management, the patient developed features of Systemic Inflammatory Response Syndrome and succumbed to his condition. On Autopsy, the pancreas was grossly enlarged and edematous with loss of surface lobulations, weighing 500gm (mean RR; 110 g). The cut surface showed extensive parenchymal necrosis accompanied by hemorrhage intermingling the substance of the gland (
The key to the acute pancreatitis management is resting the pancreas by total restriction of oral intake and by supportive therapy with intravenous fluids and analgesics. Acute respiratory distress syndrome and acute renal tubular necrosis are ominous complications. In 40-60%of patients with acute necrotizing pancreatitis, the necrotic debris becomes infected, usually by gram-negative organisms from the alimentary tract, further complicating the clinical course. Infected Necrosis has a mortality of 100%.
1 Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386(9988):85-96.
2 Dumonceau JM, Andriulli A, Deviere J, et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis. Endoscopy. 2010;42(6):503-15.
3 Sadr-Azodi O, Andrén-Sandberg Å, Orsini N, Wolk A. Cigarette smoking, smoking cessation and acute pancreatitis: a prospective population-based study. Gut. 2012;61(2):262-7.
4 Girman CJ, Kou TD, Cai B, et al. Patients with type 2 diabetes mellitus have higher risk for acute pancreatitis compared with those without diabetes. Diabetes Obes Metab. 2010;12(9):766-71.
5 Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013;144(6):1252-61.
6 Perides G, van Acker GJ, Laukkarinen JM, Steer ML. Experimental acute biliary pancreatitis induced by retrograde infusion of bile acids into the mouse pancreatic duct. Nat Protoc. 2010;5(2):335-41.
7 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(5):586-90.
8 Beger HG, Rau B, Mayer J, Pralle U. Natural course of acute pancreatitis. World J Surg. 1997;21(2):130-5.
9 Balthazar EJ, Freeny PC, van Sonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994;193(2):297-306.
10 Kumar V, Abbas A, Aster J, Robbins S, Cotran R, Perkins, J. Robbins & Cotran pathologic basis of disease. London: Elsevier Health Sciences; 2015.
11 Imrie CW. Underdiagnosis of acute pancreatitis. Adv Acute Pancreat. 1997;1:3-5.
12 Banks PA. Infected necrosis: morbidity and therapeutic consequences. Hepatogastroenterology. 1991;38(2):116-9. PMid:1855766.
13 Baron TH, Morgan D. Acute necrotizing pancreatitis. N Engl J Med. 1999;340(18):1412-7.