Pancreatitis (Acute and Chronic)

Pancreatitis Basics - Inflamed & Irritated

• Acute Pancreatitis: Sudden inflammation; potentially reversible pancreatic damage.
• Chronic Pancreatitis: Progressive inflammation; irreversible damage, fibrosis, endocrine/exocrine insufficiency.

Etiology (Acute): 📌 I GET SMASHED

• Idiopathic, Gallstones, Ethanol, Trauma
• Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hypercalcemia/Hypertriglyceridemia, ERCP, Drugs.

Etiology (Chronic): 📌 TIGAR-O

• Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent/severe acute pancreatitis, Obstructive.

⭐ Gallstones and alcohol are the most common causes of acute pancreatitis in India.

Acute Attack - Fiery Belly Fury

• Pathophysiology: Premature pancreatic enzyme activation (e.g., trypsin) causes autodigestion and inflammation.
• Clinical Features:
  • Sudden, severe epigastric pain, radiating to back; constant.
  • Nausea, vomiting, fever.
  • Abdominal tenderness.
  • Severe cases: Cullen's sign (periumbilical ecchymosis), Grey Turner's sign (flank ecchymosis).

⭐ Serum amylase and lipase are key diagnostic markers; lipase is more specific and stays elevated longer (often >3x ULN).

Acute Diagnosis & Severity - Sizing Up Sickness

• Diagnosis (2 of 3): Characteristic pain; Amylase/Lipase ≥3x ULN; Imaging findings.
• Investigations: Amylase, Lipase, LFT, CBC, CRP, Ca, LDH. USG (initial), CECT (necrosis, after 72h).
• Severity Scoring:
  • Ranson's: 📌 GA LAW (Adm: Gluc, Age, LDH, AST, WBC) + C HOBBS (48h: Ca, Hct↓, O2, BUN, Base def, Fluid). Score ≥3=Severe.
  • APACHE II: ICU.
  • BISAP (0-24h): BUN >25, Impaired mental, SIRS, Age >60, Pleural eff. Score ≥3=↑mortality.

⭐ CECT abdomen is gold standard for necrosis/complications, best after 72 hours.

Acute Management & Complications - Dousing the Flames

• Initial: NPO, aggressive IV fluids (250-500 mL/hr), analgesia.
• Specifics: ERCP for gallstone pancreatitis (if cholangitis/obstruction). Nutritional support (enteral preferred over parenteral, initiate early if severe). Antibiotics for infected necrosis ONLY.

• Local Complications: Pancreatic pseudocyst, acute necrotic collection (ANC), walled-off necrosis (WON), abscess, splenic/portal vein thrombosis.
• Systemic Complications: ARDS, renal failure, DIC, hypocalcemia (📌 Saponification of peripancreatic fat).

⭐ Early aggressive fluid resuscitation is a cornerstone of acute pancreatitis management.

Chronic Pancreatitis - Smoldering Pain & Problems

• Pathophysiology: Progressive inflammation, fibrosis, and irreversible parenchymal/ductal destruction. Leads to exocrine (maldigestion, steatorrhea) & endocrine (pancreatogenic diabetes) insufficiency.
• Clinical Features:
  • Chronic, often severe, epigastric pain radiating to back.
  • Steatorrhea, weight loss.
  • Diabetes mellitus (Type 3c).

  ⭐ Pancreatic calcification, visible on imaging, is a hallmark, especially in alcoholic chronic pancreatitis. oka

Chronic Diagnosis & Management - Long-Haul Care

• Dx: Clinical; Imaging (CT/MRCP/EUS: calcifications, ductal irregularity, atrophy); PFTs (fecal elastase <200 µg/g, secretin test).
• Rx:
  • Pain: Analgesics (NSAIDs, opioids), celiac plexus block.
  • PERT: 25,000-50,000 lipase units/meal.
  • Lifestyle: No alcohol/smoking.
  • Endoscopic (stent, stones) / Surgical (Puestow for dilated main duct, Frey for head dominant disease).
• Complications: Pseudocysts, biliary/duodenal obstruction, ↑pancreatic cancer risk.

⭐ Fecal elastase-1 (<200 µg/g) is a sensitive, specific non-invasive test for pancreatic exocrine insufficiency.

High‑Yield Points - ⚡ Biggest Takeaways

• Acute pancreatitis: Sudden epigastric pain radiating to back, ↑ serum amylase/lipase (>3x ULN).
• Most common causes of acute pancreatitis: Gallstones (cholelithiasis) and alcohol abuse.
• Severity scoring in acute pancreatitis: Ranson's criteria, BISAP, and APACHE II.
• Chronic pancreatitis triad: Pancreatic calcifications on imaging, steatorrhea, and diabetes mellitus.
• MRCP/EUS are key for diagnosing chronic pancreatitis; ERCP can be therapeutic.
• Pancreatic pseudocyst: A common fluid collection, a key complication of pancreatitis.