Hepatic Failure/GI/Endocrine Emergencies

Moderately severe AP: Characterized by local complications and organ failure that lasts less than

48 hours. Local complications for moderately severe AP resolve without intervention.

Severe AP: Characterized by persistent organ failure for more than 48 hours. Patients with severe

AP usually have one or more local complications. Mortality rates are highest for severe AP (up to

20% of cases), particularly if persistent organ failure develops within the first few days of disease.

AP is further classified according to the phase. There are two distinct phases in this disease: early and

late. The early phase usually lasts for the first week, and the late phase can last for weeks to months:

Early: Symptoms of SIRS (e.g., temperature greater than 38°C or less than 36°C, heart rate greater

than 90 beats/minute, respiratory rate greater than 20 breaths/minute or Paco2 greater than or equal

to 32 mm Hg or ventilator use, WBC greater than 12,000 or less than 4,000) with or without

transient organ failure during the first week. Inflammatory responses and organ failure are mainly

because of a response to local pancreatic injury.

Late: Complications that occur after 1 week that can last weeks to months. This phase is

characterized by persistent organ failure and the presence of local complications. The late phase

occurs only in those with moderately severe or severe AP.

Local complications with moderately severe and severe AP may include:

Peripancreatic fluid collections

Pancreatic and peripancreatic necrosis (sterile or infected). Pancreatic necrosis is an area of

nonviable pancreatic parenchyma identified by lack of enhancement on imaging, generally

involving greater than 30% of the pancreas.

Pseudocysts

Organ failure associated with AP is typically cardiovascular, respiratory, or renal dysfunction. The

modified Marshall scoring system is recommended to identify patients with AP with organ failure. A

score of 2 or more for one of these three systems indicates organ failure.

is the key enzyme responsible for the activation of pancreatic zymogens. When trypsin is inappropriately

formed and retained in the pancreas, activation of digestive enzymes inside the pancreas causes pancreatic

autodigestion and pancreatic injury.

Gallstones

Gallstone pancreatitis is the main cause of AP, responsible for 40%–70% of cases; 3%–7% of

patients with gallstones develop pancreatitis.

Gallstone pancreatitis occurs primarily in white women older than 60 years and in patients with

small stones (less than 5 mm in diameter).

Gallstone pancreatitis is usually an acute event that resolves once the gallstone has been removed

or has passed.

Excessive alcohol use is the etiology of pancreatitis in 25%–35% of cases.

Symptoms can occur as an acute episode or present as a chronic pancreatitis.

Alcohol-induced pancreatitis is more common in men than in women.

Alcohol intake for more than 5 years or greater than 50 g daily increases the risk of pancreatitis.

However, only about 5% of patients with a history of heavy alcohol consumption develop AP.