Surgery Medicine · Surgery · High Yield

Pancreatitis

Acute pancreatitis is an inflammatory condition of the pancreas triggered by inappropriate activation of pancreatic enzymes. Identifying the cause guides treatment; severity scoring guides management.

✦ The Mnemonic

"Gallstones Hit Every Troubled Troubled Individual"

Gallstones · Hyperlipidaemia/Hypercalcaemia · Ethanol · Trauma · Tumour · Idiopathic

G Gallstones Most common cause overall (40%); impaction at ampulla of Vater

H Hyperlipidaemia / Hypercalcaemia Triglycerides >11 mmol/L; hypercalcaemia — less common

E Ethanol (Alcohol) Second most common (35%); chronic pancreatitis most common cause overall

T Trauma Blunt abdominal trauma; post-ERCP pancreatitis (3–5% incidence)

T Tumour / Drugs Pancreatic cancer obstructing duct; drugs (azathioprine, thiazides, steroids, valproate)

I Idiopathic 10–20% — often microlithiasis on detailed investigation

📚 Clinical Breakdown

Additional causes: SCORPION STINGS (tropical pancreatitis), autoimmune pancreatitis (IgG4-related), mumps. The Glasgow-Imrie score predicts severity at 48 hours — 3 or more criteria = severe: PaO2 <8 kPa, age >55, neutrophils >15, calcium <2, urea >16, LDH >600, AST >200, albumin <32 ('PANCREAS' mnemonic).

Amylase is elevated in 90% of cases but is not specific (also raised in: perforated peptic ulcer, mesenteric ischaemia, salivary gland disease). Lipase is more sensitive and specific. Serum amylase returns to normal within 3–5 days; lipase remains elevated for 7–14 days — so lipase is preferred for delayed presentations.

Complications: local — pancreatic necrosis (sterile or infected), pseudocyst (enzyme-rich fluid collection), pancreatic abscess. Systemic — ARDS, AKI, DIC, shock. Infected pancreatic necrosis (CT-guided FNA confirms; gas on CT is diagnostic) requires IV antibiotics (imipenem) and, if failing, debridement — 'step-up' approach.

Most common cause Gallstones (40%), then alcohol (35%)

Severity score Glasgow-Imrie (48 hours): 3+ criteria = severe

Lipase vs amylase Lipase more specific; stays elevated longer

Pseudocyst definition Fluid collection without epithelial lining; >4 weeks

⭐ Clinical Pearl

Cullen's sign (periumbilical bruising) and Grey Turner's sign (flank bruising) indicate retroperitoneal haemorrhagic pancreatitis — tracking of blood-stained pancreatic exudate to these sites. These signs take 24–48 hours to appear and indicate severe necrotising pancreatitis with a high mortality.

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