Classification of acute pancreatitis

Macroscopic and histological features of interstitial edema and of intra- and peripancreatic fluid collections are present in 70 to 80 per cent of cases. Peripancreatic fat necrosis may be present, but associated organ dysfunction is minimal. Conservative treatment usually leads to an uneventful recovery with morphological and functional restitutio ad integrum.

Necrotizing pancreatitis is the clinically severe form of acute pancreatitis and develops in 20 to 30 per cent of cases. Macroscopic characteristics are focal or diffuse areas of devitalized pancreatic parenchyma and fat necrosis involving peripancreatic and retroperitoneal areas. The pancreatic exudate contains various vasoactive toxic substances which are responsible for remote organ failure. The extent of necrosis usually correlates with clinical severity, the incidence of organ failure, and systemic complications. Infection arises in 30 to 70 per cent of patients with necrotizing pancreatitis and is caused predominantly by gut-derived Gram-negative organisms. Infection of pancreatic necrosis is currently the main determinant of mortality in acute pancreatitis.

Postacute pancreatic pseudocysts and abscesses are rare consequences of acute pancreatitis. They do not usually occur before the fourth week after onset of symptoms and are both characterized by an inflammatory non-epithelialized wall delineating the process. Pseudocysts contain pancreatic juice and liquefied necrotic tissue, are sterile in most cases, and carry a low morbidity and mortality. Peripancreatic fluid collections, usually arising in the early course of severe acute pancreatitis, often lack a defined wall and represent a different morphological entity. Abscess appears as a collection of pus with little or no necrosis; cultures reveal bacteria or fungi. The clinical picture is usually one of abdominal sepsis without signs of acute pancreatitis. Abscesses should not be confused with infected necrosis as they differ in clinical expression and associated mortality. The incidence of these entities of acute pancreatitis is shown in Table 1...

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Table 1 Incidence of acute pancreatitis

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