complications. ultrasound abdominal ultrasonography of acute pancreatitis. on abdominal ultrasonography, the finding of a hypoechoic and bulky pancreas is regarded as diagnostic of acute pancreatitis. treatment initial management of a patient with acute pancreatitis consists of supportive care with fluid resuscitation, pain control, nothing by mouth, and nutritional support. fluid replacement aggressive hydration at a rate of 5 to 10 ml/kg per hour of isotonic crystalloid solution (e.g., normal saline or lactated ringer's solution) to all patients with acute pancreatitis, unless cardiovascular, renal, or other related comorbid factors preclude aggressive fluid replacement. in patients with severe volume depletion that manifests as hypotension and tachycardia, more rapid repletion with 20 ml/kg of intravenous fluid given over 30 minutes followed by 3 ml/kg/hour for 8 to 12 hours. fluid requirements should be reassessed at frequent intervals in the first six hours of admission and for the next 24 to 48 hours. the rate of fluid resuscitation should be adjusted based on clinical assessment, hematocrit and blood urea nitrogen (bun) values. in the initial stages (within the first 12 to 24 hours) of acute pancreatitis, fluid replacement has been associated with a reduction in morbidity and mortality. pain control abdominal pain is often the predominant symptom in patients with acute pancreatitis and should be treated with analgesics. opioids are safe and effective at providing pain control in patients with acute pancreatitis. adequate pain control requires the use of intravenous opiates, usually in the form of a patient-controlled analgesia pump. hydromorphone or fentanyl (intravenous) may be used for pain relief in acute pancreatitis. fentanyl is being increasingly used due to its better safety profile, especially in renal impairment. as with other opiates, fentanyl can depress respiratory function. it can be given both as a bolus as well as constant infusion. meperidine has been historically favored over morphine because of the belief that morphine caused an increase in sphincter of oddi pressure. however, no clinical studies suggest that morphine can aggravate or cause pancreatitis or cholecystitis. in addition, meperidine has a short half-life and repeated doses can lead to accumulation of the metabolite normeperidine, which causes neuromuscular side effects and, rarely, seizures. bowel rest in the management of acute pancreatitis, the treatment is to stop feeding the patient, giving them nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. as the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest. approximately 20% of patients have a relapse of pain during acute pancreatitis. approximately 75% of relapses occur within 48 hours of oral refeeding. the incidence of relapse after oral refeeding may be reduced by post-pyloric enteral rather than parenteral feeding prior to oral refeeding. imrie scoring is also useful. nutritional support recently, there has been a shift in the management paradigm from total parenteral nutrition (tpn) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). the advantage of enteral feeding is that it is more physiological, prevents gut mucosal atrophy, and is free from the side effects of tpn (such as fungemia). the additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration. disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the trachea even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent ng tube entry into the trachea). oxygen oxygen may be provided in some patients (about 30%) if pao2 levels fall below 70mm of hg. antibiotics up to 20 percent of people with acute pancreatitis develop an infection outside the pancreas such as bloodstream infections, pneumonia, or urinary tract infections. these infections are associated with an increase in mortality. when an infection is suspected, antibiotics should be started while the source of the infection is being determined. however, if cultures are negative and no source of infection is identified, antibiotics should be discontinued. preventative antibiotics are not recommended in people with acute pancreatitis, regardless of the type (interstitial or necrotizing) or disease severity (mild, moderately severe, or severe) endoscopic retrograde cholangiopancreatography in 30% of those with acute pancreatitis, no cause is identified. endoscopic retrograde cholangiopancreatography (ercp) with empirical biliary sphincterotomy has an equal chance of causing complications and treating the underlying cause, therefore, is not recommended for treating acute pancreatitis. if a gallstone is detected, ercp, performed within 24 to 72 hours of presentation with successful removal of the stone, is known to reduce morbidity and mortality. the indications for early ercp are: clinical deterioration or lack of improvement after 24 hours detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on abdominal ct the risks of ercp are that it may worsen pancreatitis, it may introduce an infection to otherwise sterile pancreatitis, and bleeding. surgery surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. the most common cause of death in acute pancreatitis is secondary infection. infection is diagnosed based on 2 criteria gas bubbles on ct scan (present in 20 to 50% of infected necrosis) positive bacterial culture on fna (fine needle aspiration, usually ct or us guided) of the pancreas. surgical options for infected necrosis include: minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen conventional management – necrosectomy with simple drainage closed management – necrosectomy with closed continuous postoperative lavage open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases) other measures pancreatic enzyme inhibitors are proven not to work. the use of octreotide has been shown not to improve outcomes. classification by severity: prognostic scoring systems acute pancreatitis patients recover in majority of cases. some may develop abscess, pseudocyst or duodenal obstruction. in 5 percent cases, it may result in acute respiratory distress syndrome (ards), disseminated intravascular coagulation dic. acute pancreatitis can be further divided into mild and severe pancreatitis. mostly the ranson criteria are used to determine severity of acute pancreatitis. in severe pancreatitis serious amounts of necrosis determine the further clinical outcome. about 20% of the acute pancreatitis are severe with a mortality of about 20%. this is an important classification as severe pancreatitis will need intensive care therapy whereas mild pancreatitis can be treated on the common ward. necrosis will be followed by a systemic inflammatory response syndrome (sirs) and will determine the immediate clinical course. the further clinical course is then determined by bacterial infection. sirs is the cause of bacterial (gram negative) translocation from the patients colon. there are several ways to help distinguish between these two forms. one is the above-mentioned ranson score. in predicting the prognosis, there are several scoring indices that have been used as predictors of survival. two such scoring systems are the ranson criteria and apache ii (acute physiology and chronic health evaluation) indices. most, but not all studies report that the apache score may be more accurate. in the negative study of the apache-ii, the apache-ii 24-hour score was used rather than the 48-hour score. in addition, all patients in the study received an ultrasound twice which may have influenced allocation of co-interventions. regardless, only the apache-ii can be fully calculated upon admission. as the apache-ii is more cumbersome to calculate, presumably patients whose only laboratory abnormality is an elevated lipase or amylase do not need assessment with the apache-ii; however, this approach is not studied. the apache-ii score can be calculated at www.sfar.org. practice guidelines state: 2006: "the two tests that are most helpful at admission in distinguishing mild from severe acute pancreatitis are apache-ii score and serum hematocrit. it is recommended that apache-ii scores be generated during the first 3 days of hospitalization and thereafter as needed to help in this distinction. it is also recommended that serum hematocrit be obtained at admission, 12 h after admission, and 24 h after admission to help gauge adequacy of fluid resuscitation." 2005: "immediate assessment should include clinical evaluation, particularly of any cardiovascular, respiratory, and renal compromise, body mass index, chest x ray, and apache ii score" ranson score main article: ranson criteria the ranson score is used to predict the severity of acute pancreatitis. they were introduced in 1974. at admission age in years > 55 years white blood cell count > 16000 cells/mm3 blood glucose > 11.1 mmol/l (> 200 mg/dl) serum ast > 250 iu/l serum ldh > 350 iu/l at 48 hours calcium (serum calcium < 2.0 mmol/l (< 8.0 mg/dl) hematocrit fall >10% oxygen (hypoxemia po2 < 60 mmhg) bun increased by 1.8 or more mmol/l (5 or more mg/dl) after iv fluid hydration base deficit (negative base excess) > 4 meq/l sequestration of fluids > 6 l the criteria for point assignment is that a certain breakpoint be met at any time during that 48 hour period, so that in some situations it can be calculated shortly after admission. it is applicable to both gallstone and alcoholic pancreatitis. alternatively, pancreatitis can be diagnosed by meeting any of the following: alternative ranson score ranson's score of ≥ 8 organ failure substantial pancreatic necrosis (at least 30% glandular necrosis according to contrast-enhanced ct) interpretation if the score ≥ 3, severe pancreatitis likely. if the score < 3, severe pancreatitis is unlikely or score 0 to 2 : 2% mortality score 3 to 4 : 15% mortality score 5 to 6 : 40% mortality score 7 to 8 : 100% mortality apache ii score main article: apache ii "acute physiology and chronic health evaluation" (apache ii) score > 8 points predicts 11% to 18% mortality hemorrhagic peritoneal fluid obesity indicators of organ failure hypotension (sbp <90 mmhg) or tachycardia > 130 beat/min po2 <60 mmhg oliguria (<50 ml/h) or increasing bun and creatinine serum calcium < 1.90 mmol/l (<8.0 mg/dl) or serum albumin <33 g/l (<3.2.g/dl)> balthazar score developed in the early 1990s by emil j. balthazar et al., the computed tomography severity index (ctsi) is a grading system used to determine the severity of acute pancreatitis. the numerical ctsi has a maximum of ten points, and is the sum of the balthazar grade points and pancreatic necrosis grade points: balthazar grade balthazar grade appearance on ct ct grade points grade a normal ct 0 points grade b focal or diffuse enlargement of the pancreas 1 point grade c pancreatic gland abnormalities and peripancreatic inflammation 2 points grade d fluid collection in a single location 3 points grade e two or more fluid collections and / or gas bubbles in or adjacent to pancreas 4 points necrosis score necrosis percentagepoints no necrosis 0 points 0 to 30% necrosis 2 points 30 to 50% necrosis 4 points over 50% necrosis 6 points ctsi's staging of acute pancreatitis severity has been shown by a number of studies to provide more accurate assessment than apache ii, ranson, and c-reactive protein (crp) level. however, a few studies indicate that ctsi is not significantly associated with the prognosis of hospitalization in patients with pancreatic necrosis, nor is it an accurate predictor of ap severity. glasgow score the glasgow score is valid for both gallstone and alcohol induced pancreatitis, whereas the ranson score is only for alcohol induced pancreatitis. if a patient scores 3 or more it indicates severe pancreatitis and the patient should be considered for transfer to itu. it is scored through the mnemonic, pancreas: p - pao2 <8kpa a - age >55-years-old n - neutrophilia: wcc >15x10(9)/l c - calcium <2 mmol/l r - renal function: urea >16 mmol/l e - enzymes: ldh >600iu/l; ast >200iu/l a - albumin <32g/l (serum) s - sugar: blood glucose >10 mmol/l bisap score predicts mortality risk in pancreatitis with fewer variables than ranson's criteria. data should be taken from the first 24 hours of the patient's evaluation. bun >25 mg/dl (8.9 mmol/l) abnormal mental status with a glasgow coma score <15 evidence of sirs (systemic inflammatory response syndrome) patient age >60 years old imaging study reveals pleural effusion patients with a score of zero had