Acute pancreatitis is a sudden inflammation of the pancreas due to premature activation of digestive enzymes, leading to pancreatic tissue damage.

Acute Pancreatitis – Overview
Definition:
Acute pancreatitis is a sudden inflammation of the pancreas due to premature activation of digestive enzymes, leading to pancreatic tissue damage. It can range from mild, self-limiting inflammation to severe, life-threatening necrosis with systemic complications.

Etiology (Causes):
Gallstones (Most common cause) – Obstruct the pancreatic duct, leading to enzyme accumulation and activation.
Alcohol consumption – Causes direct toxic injury and increases enzyme secretion.
Hypertriglyceridemia (>1000 mg/dL) – Leads to free fatty acid release, damaging pancreatic cells.
Hypercalcemia (e.g., hyperparathyroidism) – Causes calcium deposition in the pancreatic ducts.
Medications – Thiazide diuretics, azathioprine, steroids, valproic acid.
Trauma – Direct injury or post-ERCP pancreatitis.
Infections – Mumps, CMV, Coxsackievirus.
Autoimmune pancreatitis – IgG4-related disease.
Idiopathic – No identifiable cause in some cases.
Pathophysiology:
Premature activation of trypsin inside pancreatic acinar cells → Autodigestion of pancreatic tissue.
Release of inflammatory cytokines → Local inflammation, vascular leakage, and edema.
In severe cases, enzymatic destruction leads to necrosis, hemorrhage, and systemic inflammatory response syndrome (SIRS).
Clinical Features:
✅ Symptoms:

Severe, epigastric pain – Radiates to the back, worsens after meals.
Nausea & vomiting – Persistent, with no relief.
Fever, tachycardia – Sign of systemic inflammation.
✅ Signs:

Cullen’s sign – Periumbilical ecchymosis (suggests hemorrhagic pancreatitis).
Grey Turner’s sign – Flank ecchymosis (retroperitoneal hemorrhage).
Abdominal tenderness & guarding – Suggests peritoneal irritation.
Diagnosis:
✅ Laboratory Tests:

Serum amylase & lipase (3× upper normal limit) – Most sensitive markers.
Liver function tests (LFTs) – Elevated AST, ALT, ALP in gallstone pancreatitis.
Serum calcium – Hypocalcemia (due to fat necrosis binding calcium).
Triglycerides – >1000 mg/dL in hypertriglyceridemia-induced pancreatitis.
✅ Imaging Studies:

CT scan with contrast – Best for detecting necrosis, abscess, or pseudocyst.
Ultrasound (USG) – Identifies gallstones.
MRCP/ERCP – Used for bile duct evaluation if gallstone obstruction is suspected.
Severity Classification (Atlanta Criteria):
Mild acute pancreatitis – No organ failure or complications, self-resolving.
Moderate acute pancreatitis – Transient organ failure (48 hrs), high mortality risk.
Complications:
✅ Local Complications:

Pancreatic necrosis – Dead pancreatic tissue, risk of infection.
Pancreatic abscess – Pus collection requiring drainage.
Pseudocyst – Encapsulated fluid collection that may rupture.
Hemorrhagic pancreatitis – Bleeding into pancreatic tissue.
✅ Systemic Complications:

Sepsis & multi-organ failure (lungs, kidneys, cardiovascular collapse).

1. Acute and
chronic
pancreatitis
The department of the surgical diseases and transplantology of the
Urganch branch
of the Tashkent medical academy

2. Beautiful as celestial
angel, as demon
incidious and ills
(about the pancreas prof. Tolstoy A.D.).

3. Anatomy of the pancreas

4. Passage of bile and pancreatic juice

5. Function of the pancreas
Internal secretor External secretor
Hormones
Insulin
Glucagon
Kallecrein
Lypocain
Pancreatic juice

6. idsptpe
FermentsFerments,,
content in the pancreatic juicecontent in the pancreatic juice
Tripsin
Amilasa
Maltasa
Lypasa
Amino
acids
Simple
sugars
(glucose)
Glycerin and
fat acids
tesdrabohycar staf
(starch)

7. Acute pancreatitis
Acute disease of pancreas in the base of
which the degenerative-inflammatory
processes are laying, inducted by the
autolysis of the tissues of the gland with the
own ferments.

8. Spreading of the acute appendicitis among the acute
surgical diseases
29,2%
18,7%
14,8%
0%
20%
40%
Acute
appendicitis
Acute
cholecystitis
Acute
pancreatitis

9. Classification of the acute pancreatitis
(Atlante, 1992)
Hypostatic pancreatitis
Sterile pancreonecrosis (by the currency: light, hard;
spreading: limited, spreaded).
Infected pancreonecrosis (by the currency: light, hard;
spreading: limited, spreaded).
Pancreatic cyst
Pancreatogeneous abscess

10. Classification of the acute pancreatitis (Filin V.I., 1994)
Fermentative stage
Reactive stage
Sequestration
stage
Stage of the
upshots
Hypostatic AP
Stages of the acute
pancreatitis
Clinical forms of the acute pancreatitis
Necrotic AP
Мелкоочаговый ПНЗ
Крупноочаговый ПНЗ
Тотально-субтот. ПНЗ
Infiltrate-necrotic pancreatitis and parapancreatitis
Aseptic form
Septic form
Fermentative omentobursitis
Festering-necrotic pancreatitis and
parapancreatitis
Dissolvation
Formation of the necrotic cysts
External pancreatic fistula
Chronic pancreatitis

11. Pathogenesis of the acute pancreatitis
Exogenous reasons of the AP
Endogenous reasons of the AP
I. Biochemial components
1. Stimulation of the hormones of the GIP
2. Activity of the lipolytic ferments
3. Defeat of the fermentative balance
4. Accumulation of the intermediate exchange
5. Production of the mediators of inflammation
6. Activation of the kallecrein-kinin and thrombine system
Hypostatic pancreatitis
II. Immunological componentes
1. Reducing of the humoral and cellular immunitete
2. Autoallergic reactions
Change of the biochemistry of the tissues and defeat of the wholeness of the
tissues
Activity of the proteolytic ferments (tripsin, elastasa and defeat of the walls of
the vessels)
III. Microbe componentes
Sterile pancreonecrosis
Hemorrhagic imbibition
Festering PNZ
Ischemia of the organ

12. Acute hypostatic pancreatitis
Pathologic anatomy

13. Sterile pancreonecrosis
Pathologic anatomy

14. Infected pancreonecrosis
Pathologic anatomy

15. Clinic picture of the acute pancreatitis
•Pain localisate in the epigastria, may irradiate to the lumbar area
(Meyo-Robson symptom), right scarula (Boas symptom), right
arm and right supraclavicular area (Mussi symptom), left half of
chest.
•Retching repeating nerve-racking, sometimes becomes
untamable.
•Some patients with acute pancreatitis mark ballooned abdomen.
•The abdomen of the patient may be ballooned. The intestinal
peristaltic may be increased or doesn’t heard. The regional effort
of the pancreas marks in its projection. (Certe symptom).

16. Skin symptoms, typical to the acute
pancreatitis
•- Mondor symptom – violet
spots on the skin of body
and face, alternate with the
areas of pallor skin;
•- Holsted symptom –
cyanosis of the skin of the
abdomen;

17. •- Turner symptom – cyanosis of the skin of the lateral
surfaces of the abdomen and lumbar area;
•- Grunvald symptom – petechial rash on the skin of the
umbilical area.

18. Laboratory diagnostic
•Leucocytosis with the movement to the
left, increased SES.
•Increased amilasa (more than 128 un. by
Volgemuth).
•Hyperfibrinogenemia and increased
contention of C-reactive peptid.

19. Laboratory diagnostic
Procalcitonin test
Norma – to 0,3 ng/ml
Factor over than 0,8 ng/ml witness about
diffuse pancreonecrosis

20. Instrumental diagnostic - US
Specific signs
Increased sizes of the gland, jaggy of the borders,
not homogenous parenchyma, dilatation of the
Wirsungi’s duct, presence of the liquid in the
omental bag
Not specific signs
Presence of the liquid in the abdominal and
pleural cavities, paresis of the intestine

21. US picture of the acute pancreatitis

22. 40 ММ – NORMA,
From 40 to 50 мм – hypostatic pancreatitis,
50 -64 мм – limited pancreonecrosis,
Over 64 мм – diffuse pancreonecrosis
Definition of the distance between the aorta and left lobe of liver
Instrumental diagnostic - US

23. Specific methods of research
From the special methods of
research for the diagnostic of the
acute pancreatitis are using: X-ray,
computer tomography, US
diagnostic, endoscopic research
(esophagogastroduodeno
fibroscopy)

24. Wirsungography

25. Compute tomography

26. Nucleus-magnet tomography

27. Celiacography

28. Angiographic semiotic of the pancreas at the different forms of AP
Changes of
the arteries
of the
pancreas
Changes of the blood
circulation in the
parenchyma of the gland
Changes of the arterial
vessels around the
pancreas
Limited
pancreonecrosis
Narrowing of
the vessels,
thrombosis
of the vessels
Local reducing of the blood
circulation, later – venous
stage
Forcing back of the
common hepatica, gastro-
duodenal arteries,
sometimes the diameter of
the hepatica artery
becomes more wide than
lienalis
Diffuse
pancreonecrosis
Thrombosis
of the vessels
Reducing of the arterial
blood circulation up to full
disappearance of the
vascular picture, stopping or
absence of the
spleenogramm
Thrombosis of the main
arteries of the stomach
and duodenum

29. «Glass» at the
pancreonecrosis
«Stearine atheries» at the
pancreonecrosis
«Stearine atheries»
and threads of
fibrin at the
pancreonecrosis
Laparoscopic signs of the acute pancreatitis

30. Clinic scale of the diagnostic of the acute
pancreatitis
I. Main clinic signs (frequency of the symptoms over 70%) – pain
in the epigastria; increased diastasa of blood; retching, not giving reducing
II. Additional clinic signs (frequency of the symptoms over
20-70%) – mistakes in feeding, fat meal, alcohol, gall stone disease in anamnesis,
bilerubinemia in anamnesis over 30 mcmol/l at the absence of GSD, diarrhea, rigid
anterior abdominal wall, leucocytosis over 15*10
9
/l
III. Possible clinic signs клинические признаки (frequency of
the symptoms less than 20%) - pallor, cyanosis of the skin, enxiety,
excitement, the frequency of the heart beats more than 120 or less than 60 in a minute,
the frequency of the breathing actions more than 25 in a minute; hyperglycemy more
than 10 mmol/lat the absence of the diabetes; hypoproteinemyless than 50g/l; hematocrit
more than 45% or fibronogen more than 6 g/l; balloned abdomen (paresis of the
intestines); absence of the pulsation of the abdominal aorta at the palpation
At the presence of the 3 main signs; 2 main and 2 additional signs; 1 main , 1 additional
and 2 possible clinic signs the acute pancreatitis is diagnose

31. Comparative results of the diagnostic of the acute
pancreatitis in different clinic groups
28,4%
16,8%*
71,6%
83,2%*
0%
20%
40%
60%
80%
100%
The disease isn’t diagnosed The disease is diagnosed

32. Diseases, with which it is necessary to
differentiate the acute pancreatitis
Perforative ulcer
of the stomach
and duodenum
Thrombosis or emboly
of the mesenterial
vessels
Acute intestinal
obstruction
Acute cholecystitis
Acute appendicitis

33. Differential-diagnostic criterions of the sterile
pancreonecrosis (Tolstoy А.D., 2002)
I. Main signs:
1. Diagnostic of the hypostasis in the first 24 hours from the beginning of the
disease;
2. Hemorrhagic character of the hypostatic fluid (the color from pink to
cerise);
3. Not homogenous color of the peritoneal liquid (light in the inferior
departments, derk in the omental bag);
4. Large volume of the peritoneal liquid (coefficient of the exudation > 50
ml/hour);
5. General state of the patient (tachycardia, hypotension, olygouria) doesn’t
correspond to the minimal pathological findings.
II. Additional signs:
1. The first attack of the acute pancreatitis;
2. Obesity;
3. Absence of the GSD

34. Systems of the estimation of the state of the
patients with the acute pancreatitis
1. Scales APACHE, APACHE-II, APACHE-III;
2. Scales TISS, TISS-28, TISS-76;
3. Scales SAPS, SAPS-2;
4. Scales MPM;
5. Scale of Renson – by the clinic parameters;
6. Scale of Renson – by the data of CT;
7. Scale of M.I. Prudkov;
8. Scale of V.B. Krasnorogov;
9. Scale of А.D. Tolstoy;
10. Scale of R.V. Vashetko.

35. Estimation of the gravity of the acute
pancreatitis
Degrees of the
AP
Pulse, b/min BP, mm.h.p. Diuresis,
ml/dayт
Concentration ,
un.
Light <100 >100 >1000 <0,5
Middle 100-120 90-100 500-1000 0,5-1,0
Heavy >120 <90 <500 >1,0
I. By the clinic-laboratory factors
II. By the data of computer tomography
А Normal pancreas
В Increased pancreas without involving of the surround tissues
С Middle increased pancreas with the signs of parapancreatitis
D One parapancreatic gathering of the liquid
E two or more extrapancreatic gatherings of the liquid

36. Estimation of the gravity of the acute
pancreatitis
III. By the efficiency of the 6-12 hours basis therapy (Vashetko R.V., 2000)
1. Hungry;
2. Cold onto the abdomen;
3. Nasogastral aspiration;
4. Novocain blockade;
5. Introducing of the spasm- and cholinolitics i/v;
6. Infusion of the 2-3 liters of the cristalloids with the forced diuresis.
«all passed» - light AP;
«became better» - middle hard AP;
«hasn’t become better or became worse» - hard AP.
IV. By the character of the peritoneal exudates (Krasnorogov V.B., 2000)
Serous exudates – light AP;
Pink of ceris exudates – middle AP;
Chocolate or crimson – hard AP.

37. System of the prognosis of the gravity of AP at the firs day of thee
disease (Tolstoy А.D., 2000)
I. Main signs:
1. Skin symptoms (marble, cyanosis, echomosis on the abdomen, hyperemia of the face);
2. Hemorrhagic exudates (first 12 hours – pink-cerise color, 13-24 hours – chocolate);
3. Pulse > 120 in a minute. Или < 60 in a minute;
4. olygo- or anuria;
5. Haemolysis or fibrinolysis in the whey of blood;
6. Inefficiency or deterioration after 6-hours basis therapy
II. Additional signs:
1. Absence of the attacks of the AP in anamnesis;
2. Second half of the pregnancy or recent birth (6 months ago);
3. Immediately admition for the medical help and/or hospitalization in the first 6 hours from the
beginning of the disease;
4. Alarm diagnosis of the pre-hospital stage («infarct», «perforation» и ets.);
5. Enxiety or braking;
6. Hyperglucemy over 7 mmol/l;
7. Leucocytosis over 14*10
9
/l;
8. Bilerubinemy over 30 mcmol/l at the absence of the GSD;
9. Haemoglobine > 150 g/l.

38. Modern principles of the conducting
of the patients with the acute
pancreatitis
1. Maximal conservative treatment.
2. Differentiated conservative therapy depend on the stage
and form of the disease.
3. Constant not invasive (US, CT) and invasive (by the
indications – laparoscopy, transcutaneus puncture) control of
the state of the pancreas and surround tissues.
4. Carrying out of the operative treatment at the presence of
festering complications of the acute pancreatitis, phenomena
of the mechanical jaundice and cholangitis.
5. Minimal trauma of the pancreas.

39. Components of the conservative treatment of the
AP
I. Basis therapyтерапия:
1. Hungry;
2. Cold onto the abdomen;
3. Nasogastral aspiration;
4. Novocain blockade;
5. Introducing of the spasm- and cholinolytics i/v;
6. Infusion of 2-3 liters of the cristalloids with the forced diuresis.
II. Intensive therapeutic complex:
1. Normalization of the system and organ microcirculation (rheopolyglucin, refortan,
heparin, surolexid);
2. Extracorporal detoxication (serial plasmoferesis, cryoplasmoferesis);
3. Cytocin blockade (introducing of the antoferments);
4. Antosecretorial therapy;
5. Reconstruction of the hydro-electrolite, metabolic and peptic losses;
6. Liquidation of the “acis srtess”;
7. Correction of the immune defeats (roncoleucin, timogen, cycloferon).

40. LIACT

41. Extracorporal methods of detoxication
Detoxication with the using of
xenospleen
Haemosrbtion

42. Cathterization of the lienalis
artery

43. Catheterization of the
common hepatic artery

44. Catheterization of the celiac
trunk

45. Surgical treatment at the acute
pancreatitis is indicated
1.At the combination of the acute pancreatitis
with the destructive forms of acute
cholecystitis;
2.At the pancreatogeneous peritonitis at the
impossibility of performing of the
laparoscopic drainage of the abdominal cavity;
3.At the festering complications of the acute
pancreatitis: anscess of the omental bag,
flegmona of the extraperitoneal space .

46. Treatment of the biliar pancreatitis

47. Open operations
Panccreonecrosis
Necrectomy
Drainage of the OB

48. Laparoscopic drainage

49. Drainage and lavage of the omental bag

50. Omentobursostomy

51. to 10-14 days
Laparoscopy, sanation and drainage
of the abdominal cavity
At the ferment peritonitis (at the sterile pancreonecrosis)
Cholecystectomy, cholangiostomy,
drainage of the OB
At the presence of the destructive cholecystitis, MJ, cholangitis (at the
sterile pancreonecrosis)
Laparotomy, sanation and drainage
of the abdominal cavity
At the progress of the syndrome of the system inflammatory reaction,
inefficiency of the therapy, suspicion to the infection (at the sterile
pancreonecrosis); at the infected pancreonecrosis
over 10-14 days
Laparotomy, sanation,
necrsecvesterectomy and drainage
of the abdominal cavity
At the progress of the syndrome of the system inflammatory reaction,
inefficiency of the therapy, suspicion to the infection (at the sterile
pancreonecrosis)
At the sterile and infected pancreonecrosis
Spreading of the pancreonecrosis Located Spreaded
Access Middle laparotomy Middle laparotomy+lumbotomy at the
spreading to the extraperitoneal area
Character of the surgical intervention«close» conductionMethod of combined “open” and “close”
conduction
Optimal regime of repeating sanations«by requirement» «by programme»
Surgical tactic at the pancreonecrosis

52. Алгоритм лечебных мероприятий
Form and gravity
of the AP
Treating actions At the insufficiency
Hypostatic form Basis therapy Basis therapy including
sandostatin, ingibitors of
proteas, forsed diuresis
Sterile
pancreonecrosis, light
currency
Conservative therapy
including rheopreparates,
stimulating drugs,
parenteral feeding
LIACT(inefficiency of the
LIACT during 48-72 hours is
the indication to extracorporal
methods of detoxication,
absence of the effect of which is
the indication to the operation)
Sterile
pancreonecrosis, hard
currency
LIACT,
extracorporal methods of
detoxication
Absence of the effect during 24-
48 hours is the indication to the
operation
Infected
pancreonecrosis
Operation -

53. Chronic pancreatitis
(pancreatitis chronica)
The notion “chronic
pancreatitis” (ХП), by
modern presentations marks
chronic polyetiologic
inflammatory-degenerative
process in the pancreas,
characterizing with the long
lasting currency.

54. Classification of the chronic pancreatitis
1.Recidivate pancreatitis. This form appears at the patients, passed
the acute inflammation of the pancreas. Its essence is in
periodically repeating attacks of the acute pancreatitis.
2.Painful pancreatitis. For this form of pancreatitis the presence of
constant pain of different strength, local sated in the epigastria
and irradiate to the lumbar area and left under-rib is
characterized..
3.Pseudotumoros form of the chronic pancreatitis is characterised
with the development of significant compaction of the tissue of
the head of pancreas, that induct the compression of the bile
duct and appearance of the mechanical jaundice. The main signs
of this form of the pancreatitis are pain in the right under-rib and
epigastria, sliming down, dyspeptic defeats, slow developing
jaundice of scleras and skin.

55. Classification of the chronic pancreatitis
4. Indurative form of chronic pancreatitis develops at the gall
stone disease, diseases of big duodenal teat, chronic
alcoholism and passes with the dfeats of external and internal
function of thee pancreas.
5. Calculous form is characterized with the development of the
concrements in the parenchima of the pancreas or its ducts
system. The manifestations of the calculous pancreatitis are
similar with the clinic picture of the recidivate pancreatitis.
6. Cyst form. At this form of the pancreatitis the cysts are
develop in the tissue of the pancreas. The cyst are separated to
true and false.

56. Etiology of the chronic pancreatitis
1) Chronic alcoholism,
2) Gall stone disease and choledoholithyasis,
3) post-traumatic obstruction of the pancreatic ducts,
4) Influence of the chemical materials, including
medicines,
5) hyperlipidemy,
6) Insufficient peptid feeding,
7) Hereditary aptitude,
8) Hyperparathyreoidism (hypercalciyemia),
9) mucoviscedosis,
10) Idiopathic factors.

57. Clinic picture of the chronic pancreatitis
The main signs of the CP are:
Painful syndrome;
Digestive defeats (different dyspeptic efeats, pancreatogeneous
diarrheas);
Malabsorbtion (syndrome of insufficiency of the intestinal suction),
connected with the development of the extrasecretorial
insufficiency of the pancreas;
Sliming down; defeats of the function of the insulin apparate and
different manifestations of secondary added diabetes; calcinates in
the pancreas;
Symptoms, given by the development of the complications of the CP
biliar hypertension, pancreatis cysts, segmental portal hypertension,
pancreatic cysts, dupdenal stenosis and ets.

58. US
True cyst of the pancreas

59. Diagnostic of the chronic pancreatitis
Computer tomography: calcificates of the pancreas

60. Computer tomography
Computer tomography of the pancreas:
The cyst looks as homogenous formation.

61. Treatment of the chronic pancreatitis
•The main method of treatment of the chronic pancreatitis
is conservative.
•At the period between attacks the treatment consist of
special diet.
•The main moments at the treatment of the chronic
pancreatitis at the intensification are: liquidation of the
pain and spasm of the Oddy’s sphincter with the help of
analgesics and spasmolitics; promotion of the functional
calmness of the pancreas because of the diet.

62. Operative treatment
pancreaticojejunostomy: а – by Cattell; b – by Catlell in the modification of
А.А.Shalimov; c - by Puestow-I; d - by Puestow-II