<prompt> Which of the following does not correlate with severity of acute pancreatitis?Serum glucoseSerum amylaseSerum calciumAST  <response>: Ans. b. Serum amylase Ref: Sabiston 19e p1519-1526; Schwartz 9e p1179-1185; Bailey 26th1127-1129, 25th1139-1144; Blumgart 5th841-851; Shackelford 7e p1123-1130Level of amylase does not correlate with severity of acute pancreatitis.Assessment of Severity of Acute PancreatitisSevere pancreatitis is diagnosed if three or moreQ of the Ransons criteria are fulfilled.The main disadvantage is that it does not predict the severity of disease at the time of the admission because six parameters are only assessed after 48 hours of admission.An APACHE II score of 8Q defines severe pancreatitis. The main advantage is that it can be used on admission and repeated at any time.A CRP level 130 mgmLQ defines severe pancreatitis.Ransons Prognostic Criteria for Non-Gallstone PancreatitisAt AdmissionDuring Initial 48 Hours Age 55 yearsQ WBC 16,000Q cellsmm Blood glucose 200Q mgdL Serum LDH 350Q lUL AST 250Q UL Hematocrit fall 10Q percentage points BUN elevation 5Q mg dL Serum calcium fall to 8Q mg dL Arterial PO2 60Q mm Hg Base deficit 4Q mEqL Estimated fluid sequestration 6Q Litres Age 70 years WBC 18,000 cellsmm Glucose 220 mg dL Serum LDH 400 IUL AST 250 UL Hematocrit fall 10 percentage points BUN elevation 2 mg dL Serum calcium fall to 8 mg dL Base deficit 5 mEqL Arterial PO2 60 mm Hg Estimated fluid sequestration 4 LitresPatients with one or two criteria have a predicted mortality of less than 1, with three criteria 10 or four criteria 15; with more than seven criteria 50.Tools for Predicting Severity in Acute Pancreatitis Ready for Clinical UseOn AdmissionAt 24 HoursAt 48 Hours APACHE-II Score 8Q IL-6 Urea 60 mmolL Polymorphonuclear elastase Urinary trypsinogen 2 Urinary trypsinogen activation peptide RansonGlasgow score 3Q CRP 130Q mgmLModified Glasgow CriteriaThis system comprises eight factors. The presence of any 3 or more within 48 hours of admission defines the patient as having severe disease.Criteria During initial 48 Hours Age 55 years WBC count 15,000 cellmm Blood urea nitrogen 45 mgdL Arterial PO2 60 mm Hg Blood glucose 180 mgdL Serum LDH 600 IUL Serum calcium 8 mgdL Serum albumin 3.3 gdLAcute Physiology and Chronic Health Evaluation APACHE-II Scoring SystemAPACHE-II scoring system incorporates 12Q physiological and laboratory parameters as well as age and comorbid conditions to estimate severity of any disease process.The 12 physiologic variables are Temperature Heart rate Respiratory rate Mean arterial blood pressureQ Oxygenation Arterial pHQ Serum potassium Sodium Creatinine Hematocrit WBC countQ Glasgow Coma ScaleQScore _8 signifies severe, acute pancreatitisQIt can be determined on a daily basisQ.Recently modification of the APACHE-II scoring system with addition of obesity has been proposed.The APACHE-O scale, which adds one point for body mass index BMI between 25 and 30, and two points for BMI larger than 30.Balthazar Grading System for Acute Pancreatitis CT scan basedGrade ANormal pancreasQGrade BFocal or diffuse pancreatic enlargementQGrade CIntrinsic pancreatic alterations with peripancreatic fat inflammatory changesQGrade DSingle fluid collectionor phlegmonQGrade ETwo or more fluid collections or gas, in or adjacent to the pancreasQComputed Tomography Severity Index CTSI for Acute PancreatitisCTSI CT severity index scoring: system Balthazar grade score necrosis scoreHighest attainable score 10QPancreatic InflammationPancreatic Necrosis Normal pancreas0 None0 Focal or diffuse pancreatic enlargement1 302 Intrinsic pancreatic alterations with peripancreatic fat inflammatory changes2 30-504 Single fluid collectionor phlegmon3 506 Two or more fluid collections or gas, in or adjacent to the pancreas4 CTSI score:0-3: Mortality 3, morbidity 84-6: Mortality 6, morbidity 357-10: Mortality 17, morbidity 92Acute PancreatitisAP is mild and self-limited in most patientsQRapidly progressive inflammatory response associated with prolonged length of hospital stay and significant morbidity and mortality occur in 10-20deg of patientsMortality rate: Mild pancreatitis 1; Severe pancreatitis 10-30Q.MC cause of death in this group of patients is multiorgan dysfunction syndromeQ.First sign of Multi-system organ failure in AP commonly is impaired lung function caused by ARDSQ.Mortality in the first 2 weeks early phase; Due to multiorgan dysfunctionQMortality after 2 weeks late period; Caused by septic complicationsQPathophysiology:AP is the final result of abnormal pancreatic enzyme activation inside acinar cellsQ.Colocalization hypothesis: Cathepsin B-mediated intra-acinar cell activation of the digestive enzymes leads to acinar cell injury and triggers an inflammatory response.Intra-acinar pancreatic enzyme activation induces autodigestion of normal pancreatic parenchyma.Acinar cells release proinflammatory cytokines, which propagate the response locally and systemically.The local inflammatory response further aggravates the pancreatitis because it increases the permeability and damages the microcirculation of the pancreas.In severe cases, the inflammatory response causes local hemorrhage and pancreatic necrosisQ.Inflammatory cascade is self-limited in 80-90 of patientsQ.The mortality seen in the early phase of pancreatitis is the result of persistent inflammatory response.Risk factors:Gallstones MC and ethanol abuse 2nd MC account for 70-80 of AP casesQ.In pediatric patients, abdominal blunt trauma and systemic diseasesQ are the two most common conditions that lead to pancreatitis.Clinical Features:Cardinal symptom: Epigastric andor periumbilical pain that radiates to the back, relieved by sitting and leaning forwardQ.Up to 90 of patients have nausea andor vomiting that typically does not relieve the pain.The nature of the pain is constantQ.Dehydration, poor skin turgor, tachycardia, hypotension, and dry mucous membranes are commonly seen in patients with AP.Mild pancreatitis: Abdomen may be normal or reveal only mild epigastric tenderness.Severe pancreatitis: Significant abdominal distention, associated with generalized rebound tenderness and abdominal rigidityFlank Grey TurnerQ, periumbilical Cullens signQ and inguinal ecchymosis Fox signQ are indicative of retroperitoneal bleeding associated with severe pancreatitis.Dullness to percussion and decreased breathing sounds in the left or, less commonly, in the right hemithorax suggest pleural effusionQ secondary to AP.Diagnosis:Cornerstone of the diagnosis of AP: Clinical findings elevation of pancreatic enzyme levels in the plasmaQ.Pancreatic EnzymesA threefold or higher elevation of amylase and lipase levels confirms the diagnosisQ.Amylases serum half-life is shorter as compared with lipase.Lipase is also a more specific marker of APQ because serum amylase levels can be elevated in a number of conditions, such as peptic ulcer disease, mesenteric ischemia, salpingitis, and macroamylasemia.Patients with AP are typically hyperglycemic; they can also have leukocytosis and abnormal elevation of liver enzyme levels.Elevation of ALT levels in the serum in the context of AP has a positive predictive value of 95 in the diagnosis of acute biliary pancreatitisQ.X-ray Abdomen; Localized ileus of duodenum and proximal jejunum sentinel loopQ or that of transverse colon up to its mid point colon cut off signQ.IOC for acute pancreatitis: CECTTreatment:Cornerstone of the treatment: Aggressive fluid resuscitationQ using isotonic crystalloid solution with supplementary oxygenNarcotics are usually preferred, especially Buprenorphine morphineQ as analgesics.In Acute PancreatitisNSAIDs of choiceMetamizoleQOpiate of choiceBuprenorphineQNutritional support: Enteral nutritionQ is associated with less infectious complications and reduces the need for pancreatic surgery as compared to TPN.ERCP: Beneficial for patients with severe acute biliary pancreatitis and cholangitisQ.Laparoscopic cholecystectomy: Indicated for all patients with mild acute biliary pancreatitisQ with the exception of older patients and those with poor performance statusQ 