1. Dr Karrar Adil

2. Definition :
Acute pancreatitis is an acute inflammation of
the prior normal gland parenchyma which is
usually reversible.
It may be first attack or relapsing attacks with
an apparently normal gland in between.

3. TRAPNELL'S AETIOLOGICAL
CLASSIFICATION :
Major causes :
 Biliary tract disease 50-70%-gallstone
 Alcoholism 25%

4. Other causes :
 Trauma
 After biliary, gastric, splenic surgery
 post ERCP
 Hyperparathyroidism
 Hypercalcaemia
 hyperlipidaemia
 Diabetes
 Porphyria
 Drugs: Steroids, isoniazid, diuretics (thiazides),
azathioprine, estrogens, tetracycline, valproic acid.

5.  Viral infections (mumps, coxsackie B)
 Autoimmune pancreatitis
 Vascular diseases
 Pancreatic divisum
 Scorpion venom
 Biliary ascariasis, Clonorchis sinensis
 Mycoplasma pneumoniae
 Infectious mononucleosis
 Idiopathic

6. Definition of diagnosis of acute
pancreatitis :
The diagnosis of acute pancreatitis requires two of the
following three features:
1. abdominal pain consistent with acute pancreatitis
(acute onset of a persistent, severe, epigastric pain
often radiating to the back).
2. serum lipase activity (or amylase activity) at least
three times greater than the upper limit of normal.
3. characteristic findings of acute pancreatitis on
contrast-enhanced computed tomography (CECT).

7. Summary of the 1992 Atlanta
Classification of AP :
• Mild AP : Associated with minimal organ
dysfunction and an uneventful recovery; lacks
the features of severe AP.
• Severe AP : Associated with organ failure
and/or local complications.

8. Organ failure and systemic complications
:
 Shock: SBP < 90 mmHg.
 Pulmonary insufficiency: PaO2 ≤ 60 mmHg.
 Renal failure: Creatinine ≥ 170 µmol/L (≥ 2 mg/dL) after
rehydration.
 Gastrointestinal bleeding: 500 mL in 24 hours.
 Disseminated intravascular coagulation:
Platelets ≤ 100,000/mm3, fibrinogen < 1.0 g/L and fibrin-split
products > 80 µg/L.
 Severe metabolic disturbances: Calcium ≤ 1.87 mmol/L or ≤
7.5 mg/dL.

9. Local complications :
 Acute fluid collections.
 Pancreatic necrosis.
 Acute pseudocyst.
 Pancreatic abscess.

10. Revision of The Atlanta
Classification of AP (2008):
1st week :
(early phase) (clinical classification )
• Non-severe AP: absence of organ failure or
the presence of organ failure that does not
exceed 48 hours in duration.
• Severe AP: persistence of organ failure that
exceeds 48 hours duration.

11. After 1st week :
(subsequent phase) (morphologic classification)
• Interstitial edematous pancreatitis (IEP) (80%):
CECT demonstrates diffuse or localized enlargement
of the pancreas and normal, homogeneous
enhancement of the pancreatic parenchyma.
• Necrotizing pancreatitis (10%):
CECT demonstrates the presence of necrosis in
either the pancreatic parenchyma or the extra
pancreatic tissues. The necrosis should be further
classified into Sterile or Infected.

12. Acute interstitial pancreatitis.
Normal enhancing pancreas with
swelling and little peripancreatic fat
stranding (arrows).
Acute necrotizing pancreatitis. CT shows
nonenhancing parts of pancreatic head, neck,
and body (arrows) with normal enhancing tail
(asterisk). Note, stones in the gallbladder.

13. Determinant-based
Classification of AP (2012) :

14. Local Determinant :
The local determinant of severity is necrosis of the
pancreas and/or peripancreatic tissue.

15. Definitions
 (Peri) pancreatic necrosis : is nonviable tissue
located in the pancreas alone, or in the pancreas
and peripancreatic tissues, or in peripancreatic
tissues alone.
It can be solid or semisolid (partially liquefied).
 Sterile (peri) pancreatic necrosis : is the
absence of proven infection in necrosis.

16.  Infected (peri) pancreatic necrosis : is defined
when at least one of the following is present:
1. Gas bubbles within (peri) pancreatic necrosis on
computed tomography.
2. A positive culture of (peri) pancreatic necrosis
obtained by image-guided fine-needle aspiration.
3. A positive culture of (peri) pancreatic necrosis
obtained during the first drainage and/or
necrosectomy.

17. Systemic Determinant :
The systemic determinant of severity is a certain
degree of distant organ dysfunction due to Acute
Pancreatitis. This is covered by the term organ
failure.

18. Definitions
 Organ failure is defined for 3 organ systems
(cardiovascular, renal, and respiratory) on the
basis of the worst measurement over a 24-hour
period.
 In patients without preexisting organ dysfunction,
organ failure is defined as either a score of 2 or
more for the assessed organ system according
to the SOFA (Sepsis-related Organ Failure
Assessment) score or when the relevant
threshold is breached, as shown:

19.  Cardiovascular: need for inotropic agent.
 Renal: creatinine ≥ 171 µmol/L ( ≥ 2.0 mg/dL).
 Respiratory: PaO2/FiO2 ≤ 300 mmHg (40 kPa).
 Persistent organ failure : is the evidence of
organ failure in the same organ system for 48
hours or longer.
 Transient organ failure : is the evidence of
organ failure in the same organ system for less
than 48 hours.

20. Classification by prognostic
scoring systems :
Balthazar score :
 Also called the Computed Tomography Severity
Index (CTSI) is a grading system used to
determine the severity of acute pancreatitis.
 has a maximum of ten points, and is the sum of
the Balthazar grade points and pancreatic
necrosis grade points:

21. A. Balthazar grade :
B. Necrosis score :
CT grade+ necrosis score:
 0-3 (mild)
 4-6 (moderate)
 7-10 (severe)

22. Ranson score :

23. Thank you …