Acute pancreatitis is an inflammatory disease initiated by intrapancreatic enzyme activation, with variable involvement of other regional tissues or remote organ-systems. 

The principal symptom of acute pancreatitis is abdominal pain, localized in the upper quadrants and irradiated to the back. Nausea, vomit and fever may be also present. The course of acute pancreatitis is highly variable, and the clinical evolution often unpredictable. Whereas in the majority of patients the inflammatory process is confined to the pancreas, in other it can take a severe course with multi-organ involvement and increased mortality. According to the Atlanta classification, acute pancreatitis is divided in mild and severe forms:

• Mild acute pancreatitis (85% of cases) is characterized most of the times by pancreatic oedema, and it is a self-limiting process associated with minimal organ dysfunction and unevenful recovery. Mortality is below 2%, and depends on severe comorbidities.
• Severe acute pancreatitis (15% of cases) is associated with distant organ failure (respiratory, renal, or hepatic failure) and local complications such as necrosis, abscess or pseudocyst. Sepsis with multi-organ failure may occur, representing the principal cause of death in these patients. Mortality can be as high as 15-20%.

The etiology of acute pancreatitis not associated with disease severity. The principal causes of acute pancreatits include:

• Gallstones or common bile duct stones (biliary acute pancreatitis)
• Alcohol abuse (alcoholic acute pancreatitis)

These two types of acute pancreatitis account for 80% of cases. The remaining 20% is caused by other factors, such as: 

• Severe hypertriglyceridemia, hyperparathyroidism, hypercalcemia
• Mechanic obstruction of main pancreatic duct (e.g. tumors)
• Pancreatic trauma and iatrogenic causes (post-operative pancreatitis, post-ERCP pancreatitis
• Drugs
• Unknown causes

The diagnosis is based on symptoms, measurement of serum amylase, lipase, C-reactive protein and other inflammatory markers, and on cross-sectional imaging (CT-scan, magnetic resonance imaging).

The treatment of acute pancreatitis is initially supportive, according to the episode severity. There are not specific drugs against inflammation of the pancreas. The mainstays of therapy include fasting and enteral nutrition. Antibiotics should be limited to patients with proven infection. In severe cases with organ failure, intensive care is required. Collections and pancreatic necrosis are treated using a step-up approach. The first step is percutaneous drainage. In case of drain failure or development of large infected necrosis associated with clinical worsening, surgical drainage (with minimally invasive techniques or the classic open necrosectomy) is indicated. To learn more about pancreatic necrosectomy click here.

If known, the cause of acute pancreatitis should be also treated (e.g. cholecistectomy, ERCP, discontinuation of alcohol intake).