Practical guide to the management of acute pancreatitis

Abstract

Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas and is associated with acinar cell injury and both a local and systemic inflammatory response. AP may range in severity from self-limiting, characterised by mild pancreatic oedema, to severe systemic inflammation with pancreatic necrosis, organ failure and death. Several international guidelines have been developed including those from the joint International Association of Pancreatology and American Pancreatic Association, American College of Gastroenterology and British Society of Gastroenterology. Here we discuss current diagnostic and management challenges and address the common dilemmas in AP.

Keywords: acute pancreatitis.

Figure 1

Atlanta classification of pancreatic fluid collections.

Figure 2

CT findings in acute pancreatitis. Top left: acute interstitial pancreatitis; post-contrast portal venous phase axial CT image through the pancreas. The pancreas enhances homogeneously but there is ill-defined peripancreatic fat stranding centred on the head and body of the pancreas (white solid arrows) extending to involve the tail (white clear arrow). Note a small volume of free fluid in the lesser sac (interposed between the head of the pancreas and gastric antrum) and in the hepatorenal space. Top right: pancreatic pseudocyst; post-contrast portal venous phase axial CT image through the pancreatic tail. At this stage, acute inflammation has settled but there is a well-defined fluid density cystic lesion in the tail of pancreas (white solid arrow), with normally enhancing pancreatic tissue on either side of the lesion. Bottom left: acute necrotic collection; post-contrast late arterial phase axial CT image through the pancreas. Note patchy areas of pancreatic parenchymal hypoenhancement in the posterior head and tail of pancreas (white solid arrows). There is ill-defined peripancreatic fat stranding with free fluid crossing between retroperitoneal and peritoneal compartments, involving intra-pancreatic and extra- pancreatic tissues. Bottom right: early walled off necrosis; post-contrast portal venous phase axial CT imaging through the pancreas. At this stage, ill-defined peripancreatic collections that cross between anatomical compartments are seen to become more organised with thick enhancing walls (solid white arrows) and heterogeneous internal debris (eg, fat density components, white clear arrow).

Figure 3

Endoscopic image of lumen apposing metal stent (left) and endoscopic necrosectomy (right).