Interactive
Case
Presentation
22nd March 2023
Personal history
● 53 yo male, fit, 98 kg, 187 cm
● No prior Gastroenterology admissions
● 2 days of epigastric pain, vomiting
● Alcohol: not alcoholic; however, 2 days
prior he consumed 1L of wine
● Smoking: 25 pack-years; quit 5 years
ago
Image Source: GPOnline (Website)
Personal history
● 53 yo male, fit, 98 kg, 187 cm
● No prior Gastroenterology admissions
● 2 days of epigastric pain, vomiting
● Alcohol: not alcoholic; however, 2 days
prior he consumed 1L of wine
● Smoking: 25 pack-years; quit 5 years
ago
What would be the next step?
Image Source: GPOnline (Website)
Physical Examination
● Tachycardic, BP 110/70 mmHg
● Epigastric tenderness; no
peritoneal signs
Differential diagnosis?
Next step?
Core Tip:
Thorough patient history taking and
physical examination are essential steps
that guide further management!
Physical Examination
● Tachycardic, BP 110/70 mmHg
● Epigastric tenderness; no
peritoneal signs
Lab Tests
Abdominal US
● Amylase 12xULN
● Abnormal liver function tests
● Elevated CRP, WBC, Hct
● Gallstones in the gallbladder, slightly dilated bile
duct, edematous pancreas
Acute Pancreatitis Diagnosis:
the 2 out of 3 rule!
Clinical Lab
Presentation Parameters Imaging
Sudden onset abdominal Serum amylase and/or Characteristic findings of acute
pain suggestive of acute lipase levels >= 3 times pancreatitis on transabdominal
pancreatitis x ULN ultrasonography, contrast-
enhanced CT scan, or MRI
Acute Pancreatitis
Recent, sudden onset
Inflammation of the pancreatic tissue
• One of the most common causes for
hospitalization in case of GI diseases1
• The most frequent pancreatic disease:
26–43 cases/100.000 persons per year2
1. Petrov, M. S. et al, Nat. Rev. Gastroenterol. Hepatol, 2019
2. Aghdassi A. et al, UEG Education, 2020
Pathophysiology
• Physiologically: digestive enzymes are
stored and secreted as proenzymes
and activated in the duodenum
• Acute Pancreatitis: Activation of
enzymes occurs early, in the acinar
cells or pancreatic ducts →
(peri)pancreatic autodigestion and
inflammation
• Etiologic factors can cause AP by
direct damage to the acinar cells or
by ductal obstruction
Image Source: Osmosis (Website)
Pathophysiology
• Physiologically: digestive enzymes are
stored and secreted as proenzymes
and activated in the duodenum
• Acute Pancreatitis: Activation of
enzymes occurs early, in the acinar
cells or pancreatic ducts →
(peri)pancreatic autodigestion and
inflammation
• Etiologic factors can cause AP by
direct damage to the acinar cells or
by ductal obstruction
What can cause acute pancreatitis?
Image Source: Osmosis (Website)
Etiology
Gallstones and
Alcohol
• The two most frequent etiologies
• In some cases the etiology can be mixt
• Together, these two causes comprise ≈80%
Hypertriglyceridemia
• >1000mg/dL
• Associated with higher risk of moderate
or severe course of AP1
1. Bálint ER et al, Sci Rep. 2020
Image Source: Osmosis (Website)
Image Source: Mayo Foundation for Medical Education and Research (Website)
Disease Severity
Revised Atlanta Classification
Banks et al, Pancreas, 2013.
Local Complications
Image Source: Trikudanathan et al, 2019, Gastroenterology
Image Source: Lindström, 2010, Academic Dissertation
Image Source: Lindström, 2010, Academic Dissertation
Can we predict the patient’s evolution?
Ranson’s Criteria
BISAP Score
EASY-APP
Treatment
● No specific drug for AP
● Fluid replacement
How should we handle the fluid resuscitation in AP patients?
● Pain management
● Enteral nutrition
Early or delayed?
● Antibiotics
Routinely or selected cases?
Evolution
● Signs of organ dysfunction
● Admission to the Gastroenterology High-Dependency Unit
Evolution
● Signs of organ dysfunction
● Admission to the Gastroenterology High-Dependency Unit
What is your clinical suspicion?
Suspected Cholangitis – Urgent ERCP!
ERCP – Endoscopic Retrograde Colangio-Pancreatography
Possible complications of ERCP?
3rd Day of Admission
● Worsening abdominal pain
● Poorly tolerated NG nutrition
● Decreasing urine output
● Increasing oxygen need
● Signs of mental confusion
3rd Day of Admission
● Transferred to the Intensive Care Unit
● Required mechanical ventilation
● Need for vasopressors
8th Day of Admission
● Slowly improving clinical status
● Decreasing pain
● Well tolerated NG nutrition
● No need for mechanical ventilation
● Normal mental state
● 13th Day of admission: Returned to the Gastroenterology Unit
– Favourable further evolution
● Discharged
● Recommendation: Control in the ambulatory setting
Follow-up Visit
● Repeat imaging on Day 35
● Walled-off necrosis
Definition & Pathophysiology Etiology
01 What is acute pancreatitis and how
does it occur?
02 What are the possible causes of acute
pancreatitis?
Clinical Presentation Diagnosis
03 Signs & Symptoms, Lab Tests, Imaging 04 What are the diagnostic criteria for acute
pancreatitis?
Severity Treatment
05 Severity of the disease according to the
Atlanta classification
06 What are the treatment options for
acute pancreatitis?
Take-home Messages and Q&A
07 Some Key Concepts and discussion
Definition & Pathophysiology Etiology
01 What is acute pancreatitis and how
does it occur?
02 What are the possible causes of acute
pancreatitis?
Clinical Presentation Diagnosis
03 Signs & Symptoms, Lab Tests, Imaging 04 What are the diagnostic criteria for acute
pancreatitis?
Severity Treatment
05 Severity of the disease according to the
Atlanta classification
06 What are the treatment options for
acute pancreatitis?
Take-home Messages and Q&A
07 Some Key Concepts and discussion
Clinical Presentation
Core Tip:
Thorough patient history taking and physical
examination are essential steps!
● Abdominal pain:
Epigastric/upper abdominal pain
May irradiate to the back
Sudden onset (may be in the context of alcohol
consumption, fatty meal)
● Nausea, vomiting
● Diarrhea
Image Source: Flaticon (Website)
Patient History
● Gallstone disease
● Alcohol abuse
● Medication use
● History of weight loss
● New onset diabetes
● Previous surgery or trauma
● Hypertriglyceridemia or
hypercalcemia
● Autoimmune disease
● Genetic causes
Physical Examination
● Abdominal tenderness Grey Turner
● Abdominal distention sign
Cullen
● Fever sign
● Cullen, Grey-Turner signs
● Decreased bowel sounds
● Tachycardia, hypotension
● Dyspnea, tachypnea
● Altered state of consciousness
● Oliguria
Image Source:
Top – Statpearls (Website)
Bottom - N Engl J Med 2015; 373:e28
Laboratory Tests
Amylase, Lipase:
• 3xULN
• Do NOT correlate with disease severity &
NOT useful to monitor disease evolution!
Image Source: Labpedia (Website)
• Liver function tests
• Renal function tests
• Inflammatory markers
• Glucose levels
• Complete Blood Count
• Calcium
• Triglycerides
Image Source: Depositphotos (Website)
Imaging
Abdominal ultrasound examination
Advantages Limitations
Widely available, easily repeatable Obese patients
Non-irradiating, no impact on the kidney
Overlying bowel gas
function
Gives information on the presence of Cannot properly assess
gallstones, dilation of the bile ducts the distal bile ducts
(Peri-)pancreatic fluid collections, free fluid
in the abdomen (and/or pleura)
Areas of pancreatic necrosis
Vascular complications - thrombosis
Exclude other potential causes
Image Sourse: Terese Winslow
Image Source: Radiology Key (Website)
Image Source: 123sonography (Website)
Image Source: Wikipedia (Website)
Image Source: Mikael Häggström, M.D (via Wikimedia- Website)
Image Source: youtube.com/watch?v=mjh0toKd4Bw&list=PLfNeYuNXUfSWQ0LA3dOeXd8AmvFQl265T&index=3
Image Source: youtube.com/watch?v=mjh0toKd4Bw&list=PLfNeYuNXUfSWQ0LA3dOeXd8AmvFQl265T&index=3
Image Source: youtube.com/watch?v=mjh0toKd4Bw&list=PLfNeYuNXUfSWQ0LA3dOeXd8AmvFQl265T&index=3
Image Source: Radiopaedia (Website)
Image Source: Left – RadiologyExpert (Website)
Right – Radiology Key (Website)
Image Source: Left – Radiopaedia (Website)
Right – Medmastery (Website)
Contrast-Enhanced CT Scan
Advantages Limitations
Iodinated contrast
Provides an adequate assessment of the
material – allergies,
pancreato-biliary region
renal dysfunction!
Pancreatic edema, fluid colections, free
Ionizing radiation
abdominal fluid
Biliary stones can be
Pancreatic necrosis – best assessed >72h radiotransparent –
may be missed!
Vascular complications - thrombosis
Exclude other potential causes
Image Sourse: iStock (Website)
Image Source: Wikidoc (Website)
Image Source: Pacreapedia APA (Website)
Image Source: Pacreapedia APA (Website)
Image Source: Pacreapedia APA (Website)
Banday IA, et al.. J Clin Diagn Res. 2015
Magnetic Resonance Imaging (MRI)
Advantages Limitations
Provides adequate assessment of the
Time-consuming
pancreato-biliary region
Provides very good soft tissue
Not widely available
characterisation
Non-irradiating Costly
Safer intravenous contrast profile
• MRCP – MR Colangio-Pancreatography
Image Source: Radiology Masterclass (Website)
Image Source: Radiology Masterclass (Website)
Image Source: Radiology Masterclass (Website)
Endoscopic Ultrasound (EUS)
Advantages Limitations
High-resolution images of the Requirement of
pancreatic duct and monitored anesthesia
parenchyma and biliary system care
Assessing choledocolithiasis
Need for expert
and identifying anatomic
endosonographer
abnormalities
Obtain targeted biopsies of
Interobserver variability
lesions
Therapeutic value (e.g.
Operator dependence
pseudocyst)
Image Source: Kostalas (Website)
Additional Imaging
Sentinel Loop sign
Image Source: Loo et al, Abdominal Radiology, 2017
Take-Home Messages
● AP is the most frequent pancreatic disease
● Diagnosis is based on the 2 out of 3 rule
● Alcohol and gallstones – 80% of the cases; don’t forget
hypertrygliceridemia/hypercalcemia and post-ERCP!
● Atlanta criteria for severity classification
● BISAP, EASY-APP – easy-to-use prediction scores on
admission
● No specific treatment – therapeutic management based on fluid
replacement, pain management, early enteral nutrition
