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Acute
Pancreatitis
APractical Guide forClinicians
JohnAlbertWindsor
SavioGeorgeBarreto
AnthonyRonaldJohnPhillips
Editors
123
Acute Pancreatitis
John Albert Windsor
Savio George Barreto
Anthony Ronald John Phillips
Editors
Acute Pancreatitis
A Practical Guide forClinicians
Editors
John Albert Windsor
Department of Surgery
Faculty of Medical and Health Sciences
Surgical and Translational Research
Centre
Auckland, New Zealand
Anthony Ronald John Phillips
Surgical and Translational Research
Centre, Faculty of Medical and Health
Sciences, School of Biological Sciences
Faculty of Science
University of Auckland
Auckland, Auckland, New Zealand
Savio George Barreto
College of Medicine and Public Health
Flinders University
Bedford Park, SA, Australia
ISBN 978-981-97-3131-2 ISBN 978-981-97-3132-9 (eBook)
https://doi.org/10.1007/978-981-97-3132-9
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2024
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
If disposing of this product, please recycle the paper.
Preface
https://t.me/med1917
This book is written for all those involved in the care of patients with acute
pancreatitis. Each of you know how challenging this disease can be.
Characterized by a wide spectrum of severity; from a self-limiting disease
that does not always result in hospital admission through to being rapidly
fatal from fulminant multiple organ failure in the intensive care unit. You also
know that a specic and effective drug treatment is not available. Despite that
we have made progress. The overall mortality of acute pancreatitis has been
dropping through many incremental evidence-based advances. Together
these have had a positive impact on the clinical outcome of patients with
acute pancreatitis. However, major challenges remain and disruptive thinking
based on new paradigms are necessary if we are to subdue this common and
serious disease.
Experimental and clinical research to understand the key pathophysiological events in acute pancreatitis continues around the world. Knowledge gaps
are being lled, risk factors and disease mechanisms are being dened and
dissected, biomarkers and potential treatment targets are being highlighted.
While the history of drug trials in acute pancreatitis has been a litany of failure, there are many reasons for hope. There are so many potential treatment
opportunities that derive from our rapidly expanding knowledge of what
drives severe acute pancreatitis. But the clinical translation and implementation of this new knowledge requires a concerted and collaborative commitment, with robust and well-powered clinical trials. These trials need to ensure
that interventions are timely. The success observed with treating acute coronary syndrome and stroke highlights the importance of intervention timing.
The same urgency and hope should be applied to nding the appropriate
treatment for acute pancreatitis, which when severe has a mortality risk like
that of these diseases.
This book has been structured in two sections with the express purpose of
making the contents more readily accessible to the diversity of readership.
The rst section is more theoretical, providing chapters that cover key mechanisms driving acute pancreatitis and its panoply of complications, as currently understood. The signicant gaps in our knowledge offer avenues for
future research. The second section provides the best practical advice on key
aspects of management of acute pancreatitis in your patients. These include
determining the etiology of acute pancreatitis, predicting the severity, identifying those who require early transfer, optimizing uid therapy, selecting
analgesia, providing safe and effective nutritional support, deciding when to
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intervene with ERCP, deciding when and how to intervene for infected pancreatic necrosis, and how best to support patients with organ dysfunction and
failure.
One could argue that the separation between knowledge and practice is
articial and that these two sections should be combined. We think that for
those who want practical advice about the steps in the management of patients
with acute pancreatitis, this concise approach is helpful. We also think that
those with questions and disappointments arising from the management of
their patients and who see that progress requires new thinking and further
research will nd this approach helpful. This structure also highlights how
much of our research acquired understanding of acute pancreatitis has still to
make a difference in how we treat patients. Examples of this abound. The
elegantly described mechanisms within the acinar cell at the onset of acute
pancreatitis still await clinical application. The complexities of the cytokine
storm have been mapped, but a treatment to tame that storm has yet to be
implemented. The mechanisms driving organ failure are beginning to be
understood, but still await denitive proof of clinical impact.
The lead authors of the chapters in this book are all internationally
acclaimed experts who were carefully selected based on their recent and
notable contributions to the eld. These contributions reect cutting-edge science and substantial clinical experience. They have delivered a book that is
both stimulating and useful. It has been a pleasure working with them and
with our publisher.
Preface
JohnAlbertWindsor
SavioGeorgeBarreto
AnthonyRonaldJohnPhillips
Contents
https://t.me/med1917
Part I Clinically Relevant Science
Epidemiology of Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Jeffrey J. Easler and Dhiraj Yadav
Genetic Factors in Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . 23
David C. Whitcomb
Acinar Cell Events Initiating Acute Pancreatitis . . . . . . . . . . . . . . . . . 39
Anna S. Gukovskaya and Ilya Gukovsky
Pathophysiology of Local Pancreatic Complications . . . . . . . . . . . . . . 61
Nicholas J. Zyromski
Mechanisms in Systemic Inflammation . . . . . . . . . . . . . . . . . . . . . . . . 77
Julia Mayerle and Matthias Sendler
Mechanisms of Organ Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Vijay P. Singh, Anoop Narayana Pillai, Prasad Rajalingamgari,
and Biswajit Khatua
Part II Clinical Management
Post-ERCP Pancreatitis and Prevention . . . . . . . . . . . . . . . . . . . . . . . . 119
Venkata S. Akshintala and Vikesh K. Singh
Diagnosis and Severity of Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . 133
Enrique de-Madaria and Gabriele Capurso
Acute Pancreatitis: Pain and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . 143
Sanjay Pandanaboyana and Asbjørn Mohr Drewes
Fluids and Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Jorge D. Machicado and Georgios I. Papachristou
Nutritional Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Jenifer Barrie and Dileep N. Lobo
Antibiotics and Probiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Rupjyoti Talukdar
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Managing Biliary Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Marco J. Bruno
Managing Hypertriglyceridaemia- Associated Acute Pancreatitis . . . 191
Wei Huang and Qing Xia
Managing Idiopathic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Rowan W. Parks and Elizabeth Gleeson
Managing Local Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Hannah S. Pauw and Hjalmar C. van Santvoort
Managing Organ Failure in Acute Pancreatitis . . . . . . . . . . . . . . . . . . 235
Lu Ke, Wenjian Mao, and Weiqin Li
Contents
Part I
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Clinically Relevant Science
Epidemiology ofAcute
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Pancreatitis
JereyJ.Easler andDhirajYadav
Key Points
• AP is among the most common gastrointesti-
nal disorders responsible for hospital admis-
sion. The incidence of AP is increasing
worldwide.
• The common etiologies of AP include gall-
stones, heavy alcohol consumption, hypertri-
glyceridemia, medications, and ERCP. The
distribution of etiologies varies based on age,
sex, ethnicity, and underlying risk factors. The
severity and mortality of AP increase with age
due to a higher prevalence of risk factors and
comorbidities.
• Minimum work-up to determine the etiology
of the rst attack of AP includes the follow-
ing—a thorough history, laboratory testing for
liver function tests, calcium and triglycerides,
and trans-abdominal ultrasound. In about one
in ve patients, no etiology is detected.
• About one in ve patients with AP develops
recurrent acute pancreatitis and 10% pro-
gresses to chronic pancreatitis. Alcohol etiol-
ogy, tobacco use, and severe acute pancreatitis
J. J. Easler
Division of Gastroenterology and Hepatology,
Indiana University School of Medicine,
Indianapolis, IN, USA
e-mail: jjeasler@iu.edu
D. Yadav (*)
Division of Gastroenterology and Hepatology,
University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
e-mail: yadavd@upmc.edu
are risk factors for recurrence. The best strategy to reduce the risk of disease progression is
identication of etiology and addressing it, if
possible.
• Diabetes and exocrine pancreatic insufciency each develop in about one-third of AP
patients during follow-up.
• Necrotizing and severe AP negatively impact
quality of life and may lead to disability,
which in some patients last for many months
or even longer.
1 Introduction
Acute pancreatitis (AP) is an important public
health problem. It ranks among the most common causes of hospitalizations for gastrointestinal illnesses. In 2014, in the USA, there were
351,526 emergency room visits, 279,145 inpatient hospitalizations, and 1840 in-hospital deaths
from AP with a total expenditure for inpatient
care of $2.64 billion [1]. A number of populationbased and large single or multicenter studies have
claried various aspects of the epidemiology of
AP.The use of standardized denition and classication of severity proposed by the Revised
Atlanta Classication in 2012 has brought uniformity to reporting and made it easier to compare results between studies [2]. Well-conducted
systematic reviews and meta-analyses help in
synthesizing information from published literature while highlighting their strengths and weak-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
J. A. Windsor et al. (eds.), Acute Pancreatitis, https://doi.org/10.1007/978-981-97-3132-9_1
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