Acute Pancreatitis

Acute pancreatitis is a sudden inflammatory condition of the pancreas triggered by premature activation of digestive enzymes within pancreatic acinar cells, leading to autodigestion of the gland and surrounding tissues. Gallstones (biliary pancreatitis) and excessive alcohol consumption together account for approximately 70–80% of cases in India. Less common causes include hypertriglyceridaemia, hypercalcaemia, medications (azathioprine, valproate, thiazides), post-ERCP pancreatitis, pancreatic divisum, autoimmune pancreatitis, and idiopathic pancreatitis. The annual incidence is rising, partly driven by increasing obesity and alcohol use.

The defining symptom is severe, sudden-onset epigastric pain radiating to the back, with nausea and vomiting. Diagnosis is established by elevated serum amylase or lipase (>3 times upper limit of normal) and/or characteristic CT findings. Severity is stratified using the Revised Atlanta Classification into mild (interstitial oedematous pancreatitis, self-limiting), moderately severe (transient organ failure <48h or local complications), and severe acute pancreatitis (persistent organ failure >48h, multiorgan dysfunction). CT Severity Index (CTSI) and APACHE II score guide clinical management. Complications include pancreatic necrosis, infected necrotising pancreatitis, acute peripancreatic fluid collections, pseudocysts, and walled-off necrosis (WON).

The cornerstone of management is aggressive IV fluid resuscitation (Ringer's lactate preferred), nutritional support (enteral feeding via nasojejunal tube is superior to TPN), analgesia, and close monitoring for organ failure in an ICU setting. Antibiotics are reserved for confirmed infected necrosis. Urgent ERCP with sphincterotomy is indicated for concurrent choledocholithiasis with cholangitis. For infected pancreatic necrosis that fails to resolve, intervention is required — preferably via minimally invasive step-up approach: percutaneous drainage followed by endoscopic or video-assisted retroperitoneal debridement (VARD) before open surgical necrosectomy if necessary. Cholecystectomy is performed during the same admission (for mild biliary pancreatitis) or at 6–8 weeks (for severe cases) to prevent recurrence.