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Aetiology
Most common
Gallstones

Alcoholism
1) Obstruction ( Gallstone, Pan Ca, Congenital)
2) Drugs & toxins (Alcohol, Steroids, Diuretics)
3) Iatrogenic & traumatic (ERCP, RTA, marathon)
4) Metabolic (High Ca, Low temp, high cholesterol)
5) Infection ( AIDS. Mumps, Hep A, B, C )
6) Idiopathic

Mnemonic I get
smashed
I Idiopathic

G Gallstones

E Ethanol

T Trauma

S Steroids

M Mumps

A Autoimmune

S Scorpion/Snakes

H Hyperlipidaemia/hypercalcaemia

E ERCP

D Drugs

History & Investigations

Hx

Previous gallstones
Alcohol intake
Family history
Drug intake
Exposure to viral causes

Initial Ixs
Pancreatic enzymes, LFTs
US of gallbladder

Follow up Ixs
Fasting plasma lipids
Fasting plasma calcium
Viral antibody titre
Repeat biliary US, MRCP, CT

Clinical features
Acute attack
Acute abdominal pain
Distension
Abdo tenderness,
guarding, absent bowel
sounds
Minimal systemic illness
Moderate tachycardia

Severe Attack
Severe acute abdominal
pain
Severe toxaemia & shock
Generalised
peritonitis(rigidity,
guarding, -ve BS)
ARDS

Pancreas Severity prediction

Modified Glasgow Scoring

Mnemonic Criterion
P
PaO2

Positive when

A
N
C
R
E
A
S

>55 years

Age
Neutrophil count
Calcium (blood)
Raised plasma urea
Enzyme- plasma LDH
Albumin (plasma)
Sugar-plasma glucose

< 8 kPA or 60
mm Hg
>15x 10 9/L
<2 mmol/L
>16 mmol/l
>600 i.u/L
<32 g/L
>10 mmol/L

Early identification of severe

pancreatitis (after Ranson)
3 or more of the following features:
On admission
Age >55 years (non-gallstone pancreatitis)
70 years (gallstone pancreatitis)
Leucocyte count >16 x 10 9/L
Blood Glucose > 10 mmol/L in a non-diabetic patient
LDH >350 i.u./L
Serum glutamic oxaloacetic transaminase (SGOT) > 100 u/l

Severity scoring
During the next 48 hours
Haematocrit increase of >10%
Serum urea increase of >10 mmol/L despite adequate IV
therapy
Hypocalcaemia (cca <2 mmol/L)
Low arterial PO2 (<8 kPa or 60 mmHg)
Metabolic acidosis (base deficit more >4 mEq/L)
Estimated fluid sequestration >6 L

Management
NBM + IV fluid (good)
O2
NG tube and gastric aspiration if vomiting

IV Abx

Catheterise if 3 or more score

ITU care

Fluid & electrolyte management

Treatment of hypocalcaemia

Ventilatory support

Laparotomy and pancreatic necrosectomy

Complications
Multi-organ failure

Direct local pressure effect, inflammation and

hypotension-portal vein thrombosis
Local pressure+ hypotension-> bowel
ischaemia(commonly transverse colon secondary to
middle colic artery)
Pseudoaneurysms- eg splenic artery because of
inflammatory damage to the arterial wall and fluid
collections around them
Internal pancreatic fistula esp if necrosis causes
disruption of pancreatic duct or the wall of a
pseudocyst, Result: pancreatic ascites, mediastinal
pseudocystsm enzymatic mediastinitis or pancreatic
pleural effusions
Late complications
DM
Intestinal malabsorption due to loss of pancreatic
secretions

References
Essential Surgery. Problems, diagnosis &
management H George Burkitt, C Quick, J
Reed