acute pancreatitis is an acute inflammation of the pancreas and is a condition that carries a 10 to 25 mortality rate it occurs when the enzymes within the pancreas become abnormally activated leading to damage of the pancreas overall the pancreas has endocrine functions meaning release of substances into the blood such as insulin glucagon and somatostatin as well as exocrine functions meaning secretion of substances via a duct onto another surface in this case the secretion of pancreatic juice into the duodenum via the pancreatic duct this pancreatic juice plays a key role in acute pancreatitis it contains bicarbonate to neutralize acid coming from the stomach which is important because the juice also contains digestive enzymes that work better in more neutral environments these are trypsinogen elastase lipase and amylase that break down proteins fats and carbohydrates respectively normally trypsinogen is converted into its active form trypsin within the duodenum however in acute pancreatitis this occurs within the pancreas generating inflammation edema vascular injury and ultimately ischemia and necrosis of the pancreas mild pancreatitis or interstitial edimatous pancreatitis is the term used when there is primarily inflammation in response to cell injury while severe or necrotizing pancreatitis is the term used when necrosis is predominant the causes for acute pancreatitis can be remembered with the famous mnemonic i get smashed briefly it stands for idiopathic gallstones which are the most common cause followed by ethanol or alcohol as the second most common cause globally the others stand for trauma steroids microbiological causes like mumps hepatitis or tuberculosis a is for autoimmune pancreatitis s for scorpion stings h for hypocalcemia and hypertriglyceridemine e for ercp which is notable because ercp is a treatment for gallstones in the common bile duct and may be used as a treatment for acute pancreatitis e also stands for emboli that may generate ischemia d is then for drugs including diuretics like furosemide and thiazide glyptons opiates vaporic acid and estrogen preparations signs and symptoms of acute pancreatitis include abdominal pain that is mostly epigastric with radiation to the back and is often described as a band-like sensation around the upper abdomen there is often also nausea and vomiting and features such as a loss of appetite and fever if the acute pancreatitis was caused by a gallstone they may also be features of gallstone disease on examination there is typically epigastric tenderness and in severe cases may have rebound tenderness distension and guarding which may suggest peritonitis signs such as cullens and grey turner signs may also be present which are bruising around the umbilicus and flanks respectively which are an indicator for retroperitoneal hemorrhage the inflammatory response leads to the secondary manifestations of pancreatitis from capillary permeability potentially causing shock as well as others such as acute respiratory distress syndrome disseminated intravascular coagulation or multi-system organ failure ultimately the diagnosis of acute pancreatitis comes from a combination two out of three of abdominal pain elevated lipase or amylase levels typically three times the upper reference range in the case of amylase or imaging findings indicative of acute pancreatitis ultrasound or ct abdomen and pelvis are options with a latter also providing more information if other intra-abdominal pathologies are present but typically imaging after 48 hours is considered more indicative as the inflammation and necrosis of the pancreas may not have fully developed before then other investigations may include liver function tests as gallstones are the most common cause also hypocalcemia may be seen this is because when fat is broken down fat necrosis can occur which leads to release of free fatty acids which bind to calcium and deposit within the fatty tissue therefore decreasing the available free calcium due to damage to the islets of bladder hands which produce insulin they may also be hypoglycemia a useful score is the glasgow emery score which is used to predict the severity of the pancreatitis based on several parameters which can be remembered with pneumonic pancreas this stands for an oxygen partial pressure below 8 kilopascals age above 55 neutrophils meaning leukocytosis above 15 times 10 to the nine per liter c for calcium levels below 2 millimoles per liter or 8 milligrams per deciliter and r is for renal function in the form of a raised blood urea nitrogen e is for enzymes including lactate dehydrogenase levels above 600 international units per liter or aspartate transaminase levels above 200 units per liter a is then for albumin below 32 grams per liter and s is finally for sugars with hyperglycemia above 10 millimoles or 180 milligrams per deciliter counting each is worth a single point and a higher score indicates a higher mortality risk the treatment involves identifying and correcting the underlying cause for example an ercp may be done if a gallstone is thought to be causing the acute pancreatitis otherwise it is primarily supportive treatment with fluids being a key component often these patients will require a large volume because the degree of inflammation leads to a fluid extravasation and therefore intravascular depletion alongside the fluids a strict monitoring of the fluid input and output is required which usually involves a catheter a urine output of more than 0.5 milliliters per kilogram per hour should be achieved and fluid requirements will be constantly monitored values such as the blood urea nitrogen along with the clinical picture will aid in determining how much fluid is needed next we have analgesia which will also be required due to the likely pain and opioids have in fact been shown to be safe in patients with acute pancreatitis as well as others such as paracetamol for nutrition a nasogastric tube may be used which aids if the patient is vomiting as well as providing some enteral feeding when tolerated generally prophylactic antibiotics are not routinely started however if an infection is suspected then in that case they would be started surgery is indicated in some cases these include infected pancreatic necrosis or if there are complications such as a pancreatic pseudocyst that does not resolve spontaneously an abscess obstruction or vascular complications or if there is diagnostic uncertainty