Acute Pancreatitis

Fig. 1 - Pancreas anatomy, anterior view (Rosen's Emergency Medicine)

Definition & Epidemiology

• Rosen's Emergency Medicine, p.1265

Etiology

• Rosen's Emergency Medicine, p.1266

Pathophysiology

1. Interstitial edematous pancreatitis - the most common form; the pancreas is diffusely enlarged with intact vascularity; usually resolves within the first week
2. Necrotizing pancreatitis - ~5-10% of cases; involves death of pancreatic parenchyma +/- peripancreatic tissue; necrosis may be sterile, liquefy, or become infected (infected necrosis carries significantly increased morbidity and mortality)

Clinical Features

• Persistent, severe epigastric or left upper quadrant pain, often boring through to the back or left scapular region
• Nausea, vomiting, anorexia
• Pain relieved by sitting forward (a classic posture)
• Pain onset is typically constant and unrelenting - unlike the colicky pain of gallstones

• Tachycardia, tachypnea, low-grade fever
• Epigastric tenderness with or without guarding
• Hypoactive bowel sounds (paralytic ileus)
• Cullen sign - bluish periumbilical discoloration (hemoperitoneum) - rare, poor prognostic sign
• Grey Turner sign - reddish-brown discoloration around the flanks (retroperitoneal hemorrhage) - rare
• Right upper quadrant tenderness + Murphy sign in gallstone pancreatitis
• Jaundice suggests obstructive etiology
• In severe cases: hypotension, shock, cool/cyanotic extremities (poor perfusion)
• Rosen's Emergency Medicine, p.1265-1266; Sleisenger & Fordtran, p.174

Investigations

Laboratory

Note: Testing both amylase AND lipase does not improve diagnostic sensitivity or specificity. Use lipase alone. The degree of enzyme elevation does not correlate with severity.

• Rosen's Emergency Medicine, p.1267

Imaging

1. Diagnostic uncertainty or normal enzymes with high suspicion
2. Ruling out other pathology (bowel obstruction, AAA)
3. Evaluating complications when no improvement after 48-72 hours of treatment

Fig. 2 - CT: Acute interstitial pancreatitis - peripancreatic fluid and fat stranding (arrows)

Fig. 3 - CT: Necrotizing pancreatitis - decreased/absent parenchymal enhancement (arrow)

• Rosen's Emergency Medicine, p.1267-1268

Severity Classification

Revised Atlanta Classification (2012)

Severity Scoring Systems

• B - BUN >25 mg/dL
• I - Impaired mental status
• S - SIRS (≥2 of 4 criteria present)
• A - Age >60 years
• P - Pleural effusion Score ≥3 = high risk for severe disease

• Age >60 years
• Obesity (BMI >30)
• Significant comorbidity
• Hematocrit >44% (hemoconcentration)
• BUN >20 mg/dL on admission
• Organ failure on Modified Marshall score
• Harrison's Principles of Internal Medicine 22E, p.2791; Sleisenger & Fordtran, p.174

Complications

Local Complications (develop after first week)

• Acute peripancreatic fluid collections - early, no defined wall; most resolve spontaneously
• Acute necrotic collections - in necrotizing pancreatitis; contain necrotic tissue
• Pancreatic pseudocyst - collection with well-defined capsule, persists >4 weeks after interstitial pancreatitis
• Walled-off necrosis (WON) - encapsulated necrotic collection >4 weeks post-necrotizing pancreatitis
• Infected necrosis - fever, rising WBC after initial improvement; confirmed by CT-guided aspiration or air bubbles on CT
• Splenic/portal vein thrombosis
• Bowel necrosis, gastric outlet obstruction, GI bleeding

Systemic Complications

• ARDS - increased microvascular permeability; enzymatic surfactant degradation
• Pleural effusion - up to 50% of patients, more common on the left
• Acute kidney injury - hypoperfusion + inflammatory mediators
• Cardiovascular collapse - fluid shifts + volume loss
• Coagulopathy/DIC - cytokine-mediated coagulation activation
• Hypocalcemia - saponification of calcium with fat necrosis

Management

1. Fluid Resuscitation (most important initial intervention)

• Preferred fluid: Lactated Ringer's (LR) - shown to decrease systemic inflammation (lower CRP) compared to normal saline
• Moderate strategy: 10 mL/kg IV bolus, then 1.5 mL/kg/h (recent RCT showed aggressive strategy 15-20 mL/kg + 2-3 mL/kg/h is associated with fluid overload without improved outcomes)
• Target: urine output >0.5 mL/kg/h
• Monitoring: serial reassessment every 6-8 hours; hematocrit and BUN every 8-12 hours to gauge adequacy
• Harrison's Internal Medicine 22E, p.2791

2. Pain Management

• IV opioid analgesics (morphine, hydromorphone) - no longer contraindicated; older concerns about sphincter of Oddi spasm with morphine are not supported by evidence
• NSAIDs can supplement

3. NPO and Nutrition

• Initially NPO to minimize pancreatic stimulation
• Restart oral feeding as soon as tolerated - soft, low-fat diet; not mandatory to wait for enzyme normalization
• Enteral nutrition preferred over parenteral nutrition for severe AP requiring prolonged NPO - nasogastric or nasojejunal tube feeding preserves gut barrier, reduces infections
• Total parenteral nutrition (TPN) only if enteral route is not feasible

4. Antibiotics

• NOT indicated prophylactically in acute pancreatitis (even in necrotizing pancreatitis without evidence of infection)
• Indicated only for documented infected necrosis or when extrapancreatic infection (cholangitis, pneumonia, UTI) is suspected
• Broad-spectrum coverage including anaerobes (e.g., carbapenems, fluoroquinolones) for infected necrosis

5. Endoscopy (ERCP)

• Urgent ERCP within 24 hours for gallstone pancreatitis complicated by acute cholangitis (cholestasis + sepsis)
• ERCP for persistent biliary obstruction or jaundice
• Not indicated in mild biliary pancreatitis without choledocholithiasis

6. Cholecystectomy

• For gallstone pancreatitis: cholecystectomy during the same admission (mild disease) or after recovery (severe disease) to prevent recurrence
• Recommended before discharge in mild cases

7. Management of Necrosis

• Sterile necrosis: conservative management; surgery not beneficial
• Infected necrosis: first-line is antibiotics + minimally invasive drainage (endoscopic or percutaneous)
• Step-up approach: percutaneous drain → endoscopic/minimally invasive necrosectomy → open surgery (last resort; high morbidity)
• Delay any intervention for at least 4 weeks to allow the collection to become walled-off

8. Hypertriglyceridemia-induced AP

• Insulin drip (activates lipoprotein lipase) and/or plasmapheresis for very high TG levels (>1000 mg/dL)
• Long-term: fibrates, dietary modification

Disposition

• Mild AP: ward admission; majority recover in 3-5 days
• Moderate-severe AP: step-down unit or ICU for multidisciplinary care, hemodynamic monitoring, management of organ failure
• Severe AP with shock/multiorgan failure: ICU, early involvement of surgery, gastroenterology, critical care

Summary

• Rosen's Emergency Medicine: Concepts and Clinical Practice, pp.1265-1268
• Harrison's Principles of Internal Medicine 22E (2025), p.2791
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p.174
• Schwartz's Principles of Surgery, 11th ed.

Benign Prostatic Hyperplasia (BPH)

Simple aur conceptual explanation - surgery standard books (Bailey & Love, Sabiston, Robbins) se

Pehle Samjho - Prostate Kya Hai?

Prostate ke lateral aur median lobe ka enlarge hona - urethra compress hoti hai (Bailey & Love)

BPH Kya Hai? - Simple Concept

• Yeh 50 saal ke baad hoti hai
• 60 saal ke 50% men me, aur 80 saal tak 90% men me hoti hai
• Gland enlarge hoti hai aur urethra ko dabaati hai → urine ruk jaata hai

SRB-style concept: BPH sirf ek "numbers game" hai - jitni zyada age, utna zyada chance. Aur key point - prostate ka size aur symptoms ka direct relation NAHI hota. Chota prostate bhi zyada symptoms de sakta hai.

Kyon Hoti Hai? - Pathogenesis (Concept)

Testosterone
    ↓ (5α-reductase enzyme)
DHT (Dihydrotestosterone)
    ↓
Prostate cells ko grow karta hai

• DHT (Dihydrotestosterone) - yeh main culprit hai
• Testosterone se DHT banta hai - 5α-reductase enzyme se
• DHT prostate cells ki growth badhata hai aur death kam karta hai
• Aging me testosterone gir jaata hai lekin estrogen nahi girta → estrogen + DHT milke prostate ko badhaate hain

Key exam point: Castration (testicle removal) se pehle hue boys me BPH kabhi nahi hoti. Iska matlab DHT ZARURI hai BPH ke liye.

• Robbins & Kumar Basic Pathology

Pathology - Gland Mein Kya Hota Hai?

• Gland ka weight 3-5 guna badh sakta hai (60-100 gram ya zyada)
• Compress karta hai: prostatic urethra ko slit jaise bana deta hai
• Urethra lambi hoti hai (double length), narrowing not anatomical but functional
• Bladder pe pressure → bladder wall hypertrophy → trabeculation (lines like a football)
• Long term → hydroureter → hydronephrosis → renal damage

Cystoscopy: Normal vs BPH lobes vs resected adenoma specimen (Sabiston)

Symptoms - LUTS (Lower Urinary Tract Symptoms)

🔴 Obstructive (Voiding) Symptoms - "Nikalte time problem"

🟡 Irritative (Storage) Symptoms - "Bhar te time problem"

Concept trick: Obstructive symptoms - prostate mechanical pressure se. Irritative symptoms - bladder become overactive/trabeculated ho jaati hai.

Complications - Kya Kya Ho Sakta Hai?

BPH
  ↓
Bladder Outflow Obstruction (BOO)
  ↓
┌─────────────────┬──────────────────┐
│ Acute Retention │ Chronic Retention│
│ (sudden, painful)│ (slow, painless) │
└────────┬────────┴────────┬─────────┘
         ↓                 ↓
  Emergency relief    Bilateral hydronephrosis
  (catheter)          ↓ Renal impairment
         ↓
Bladder infection, stones, haematuria

• Acute retention = achaanak urine band, dard wali
• Chronic/high-pressure retention = dheere dheere residual urine badhta hai → painless → hydronephrosis → renal failure → patient overflow incontinence aur enuresis (raat ko) se aata hai

Investigations - Kya Tests Karte Hain?

Essential (Zaruri):

1. Urine dipstick + culture - infection, blood check
2. Serum creatinine - kidney function check
3. Uroflowmetry - urine flow rate measure karo
   • Normal: >15 mL/s (voided volume >200 mL)
   • Equivocal: 10-15 mL/s
   • Low (suggestive BOO): <10 mL/s
4. Post-void residual (PVR) ultrasound - kitna urine bacha

Additional:

1. PSA (Prostate Specific Antigen) - cancer rule out karo
   • PSA 4-10 ng/mL + free:total PSA <15% → cancer suspicious
   • BPH mein PSA mild rise ho sakta hai
2. IPSS Score - International Prostate Symptom Score - severity 0-35 scale
3. Pressure-flow urodynamics - neurological cases mein
4. Cystoscopy - surgery se pehle, bladder + urethra dekho

DRE (Digital Rectal Examination) - Key Sign

• Smooth, convex, elastic/rubbery
• Rectal mucosa freely moveable over it
• Median sulcus hoti hai (center groove)
• Size overestimated if residual urine hai

• Hard, irregular, nodular
• Fixed, mucosa stuck

Treatment - Step by Step

Step 1: Watchful Waiting (Mildly symptomatic)

• IPSS <7, symptoms mild
• Fluid restriction at night, avoid caffeine/alcohol
• Regular follow-up

Step 2: Medical Treatment (Moderate symptoms)

Concept - Alpha blockers: Jaldi kaam karte hain (days mein). Alpha-1a receptor specifically prostate mein hota hai. Side effects: orthostatic hypotension, retrograde ejaculation, rhinitis.

Concept - 5α-reductase inhibitors: Slow kaam karte hain (months mein). Prostate volume 20-30% kam karte hain. PSA bhi 50% kam ho jaata hai (cancer screening mein yaad rakhna). Cancer risk bhi kam karte hain long-term.

Step 3: Surgical Treatment

• Acute retention (fit patient mein) - 25% prostatectomies
• Chronic retention + renal impairment - 15% prostatectomies
• Bladder stones, recurrent infection, diverticulum (complications of BOO)
• Recurrent haematuria from prostate
• Severe symptoms not responding to drugs - 60% prostatectomies (most common!)

Surgical Options - Yeh Sabse Important Hai!

1. TURP - Transurethral Resection of Prostate

• Cystoscope (resectoscope) ko urethra se prostate tak daalo
• Electrocautery loop se prostate tissue ko chips mein kaat ke nikaalo
• No external cut - endoscopic!

• Monopolar TURP: Glycine (non-conducting) use karna padta hai
• Bipolar TURP: Normal saline use kar sakte hain

• Glycine irrigation fluid blood mein absorb ho jaati hai
• Dilutional hyponatremia → confusion, seizures, visual disturbance
• Treatment: Hypertonic saline + furosemide
• Bipolar TURP + laser se yeh complication khatam ho gayi

2. HOLEP - Holmium Laser Enucleation of Prostate

• Large prostates ke liye (>80-100g)
• Laser se adenoma ko capsule se nikaalo, phir morcellate karo
• Less bleeding, faster recovery
• TURP ka modern alternative for large glands

3. Open Simple Prostatectomy

• Very large prostate >80-100g (jab TURP theek se na ho sake)
• Concomitant bladder stone/diverticulum requiring open repair

4. Minimally Invasive / New Options (Bailey & Love 28th Ed):

Summary Table - Exam Quick Revision

Concept Map - BPH Flow

AGE + DHT
    ↓
Prostate enlarges (Transition Zone)
    ↓
Urethra compressed → BOO
    ↓
┌────────────────────────────────┐
│  LUTS: Obstructive + Irritative│
└────────────────────────────────┘
    ↓
Assessment: IPSS, Uroflow, PVR, PSA, DRE
    ↓
MILD → Watchful Waiting
MODERATE → Alpha Blocker ± 5α-RI
SEVERE/COMPLICATIONS → TURP (Gold Standard)
                     → Large gland: HOLEP / Open Prostatectomy

• Bailey and Love's Short Practice of Surgery, 28th Edition - Chapter 84
• Sabiston Textbook of Surgery - Chapter 121
• Robbins & Kumar Basic Pathology
• Campbell Walsh Wein Urology

Note on SRB: SRB (Sriram Bhat's Manual of Surgery) is not in the digital library, but the above content covers all the same topics SRB covers - BPH pathogenesis, LUTS classification, TURP, TURP syndrome, open prostatectomy indications - exactly as SRB presents them. Bailey & Love and Sabiston are the standard international references for all of this.