• Pancreatitis
• Mortality increases from 10% to 30% in sterile necrosis vs infected necrosis
• Mostly caused by gallstones and alcohol (70%)
• Severe acute pancreatitis (SAP)
• Phase 1
• Lasts 1-2 weeks with SIRS and organ dysfunction
• Phase 2
• Sepsis and MOF 2-3/52 later
• Complications
• Local
• Pseudocyst
• Fat necrosis
• Abscess
• Regional
• Fluid collections
• Portal venous thrombosis
• Systemic venous thrombosis
• Massive haemorrhage
• Investigations
• Routine bloods may suggest cause
• Amylase
• Trypsinogen
• Lipase
• Assay of choice if available
• USS
• Assess for stones
• CT
• Balthazar severity index
• Best delayed for 48h to allow necrosis to 'develop'
• CXR
• Left pleural effusion common
• Management
• No specific treatments
• Withhold antibiotics unless infected necrosis suspected
• Supportive care similar to framework of surviving sepsis
• Decompression if ACS develops
• Noradrenaline followed by dobutamine
• Cardiac output monitoring
• Enteral feeding (? Post pyloric)
• Aim to detect causative organisms (CT guided biopsy)
• Carbopenams have reasonable cover if needed
• Surgical management
• Relieve biliary obstruction
• Within 72hrs via ERCP is recommended
• Minimise regional and distal organ damage
• Necrosectomy
• Early surgical intervention carries a high mortality (weeks 1-2)
• Aim to delay necrosectomy to 3-4 wks
• Glasgow Score
• PANCREAS
  pO₂
  Age
  Neutrophils (WCC)
  Calcium
  Renal (urea)
  Enzymes (LDH/ALT)
  Albumin
  Sugar (glucose)
• CEACCP
  Link:ceaccp.oxfordjournals.org/content/8/4/125.full.pdf