The most common presenting sign of acute pancreatitis is pain on the epigastric area involving the upper left quadrant of the abdomen. Abdominal pain is aggravated with intake of drinks and food especially those with high fat content. Patient usually appears prostrated because pain becomes worst when lying flat on the back. Referred pain is usually felt at the back by the edge of the lower left shoulder blades.

General appearance will convey an ill-looking person with heavy sweating. Patients may also complain of fever, nausea and vomiting in the early part of the disease. Other gastrointestinal symptoms like feeling of fullness, intractable hiccups, clay-colored stools, indigestion and sometimes jaundice are also associated with acute pancreatitis.

• Fever

  Hantaviruses cause potentially fatal two different systemic infectious diseases in humans named as hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome. [ncbi.nlm.nih.gov]

• Severe Pain

  The main symptom of acute pancreatitis is a severe pain that develops suddenly in the centre of your tummy. This aching pain often gets steadily worse and can travel along your back. [nhs.uk]

  Get an urgent GP appointment or go to A&E if: you have a severe dull pain in the middle of your tummy just under the ribs the pain moves to your back and the left shoulder blade The pain can come on after eating a large meal or 6 to 12 hours after drinking [beta.nhs.uk]

  If there is severe pain, at least one type of pain relief (e.g. paracetamol, non-steroidal anti-inflammatory drugs, opioids) is generally used. [cochrane.org]

• Anorexia

  A 36 year old male presented to the emergency department with severe epigastric pain, nausea, vomiting without hematemesis, diarrhea and anorexia. He presented with respiratory distress, shock and fever at the emergency. [ncbi.nlm.nih.gov]

  Review Topic QID: 107797 M2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (M2.GI.4692) A 39-year-old male presents to the emergency department with acute abdominal pain and anorexia for two days. [medbullets.com]

  The most common symptoms and signs include severe, dull epigastric pain, nausea, vomiting, diarrhea, anorexia and fever. Alcohol consumption and biliary stone disease cause most cases of acute pancreatitis. [symptoma.com]

  Assessment History Features: recent onset ear pain (irritability in pre-verbal children), fever, anorexia, vomiting, lethargy. [rch.org.au]

• Acute Intermittent Porphyria

  Diabetes mellitus type 2 is associated with a 2.8-fold higher risk.[23] Less common causes include pancreatic cancer, pancreatic duct stones,[24] vasculitis (inflammation of the small blood vessels in the pancreas), and porphyria—particularly acute intermittent [en.wikipedia.org]

• Acutely Ill Patient

  Here we present two cases of acutely ill patients that were confirmed to have acute pancreatitis radiologically but with serum amylase and lipase levels that remained within the normal range throughout their illnesses for both patients. [pancreas.imedpub.com]

• Pleural Effusion

  She had an extended hospital course because of severe disease, characterised by systemic inflammatory response syndrome, pleural effusion and ascites but was successfully managed conservatively with bowel rest, hydration and pain management. [ncbi.nlm.nih.gov]

  Demonstration of a pleural effusion indicates severe disease. [academic.oup.com]

  The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the “traditional” multifactorial scoring systems: Ranson's, Acute [doi.org]

  Similarly, hepatic etiologies should be considered in those that present with ascites or pleural effusion. [clinicaladvisor.com]

• Tachypnea

  The patient rapidly deteriorated, presenting with dyspnea, tachypnea, productive cough, abdominal pain, and onset of fever. C-reactive protein was at 270 mg/L, with a rise in serum lipase (670 UI/L, N: 13-60). [ncbi.nlm.nih.gov]

  The patient may have tachycardia and fever, as well as tachypnea if aspiration pneumonia or pleural effusion or ARDS is present. [clinicaladvisor.com]

  Abdominal distension A ggravating factors: Eating or drinking (specially alcohol) A lleviating factors: Leaning forward, Curl up (Fetal position) Signs of Acute Pancreatitis General condition: Distressed, Anxious Vitals: Fever, Tachycardia, Hypotension, Tachypnea [epomedicine.com]

  The physical examination findings may be normal or reveal fever, hypotension, tachycardia, tachypnea, or diaphoresis. [aafp.org]

  Symptoms of severe pancreatitis development include tachycardia, hypoxia, tachypnea, and changes in mental status. [1] [2] Complications that may occur with severe forms of this disease include pancreatic fluid-filled collections (57% of cases), pseudocysts [physio-pedia.com]

• Decreased Breath Sounds

  Chest examination findings include development of crackles, decreased breath sounds and dullness to percussion associated with pneumonia or pleural effusion. [clinicaladvisor.com]

  He was tachypneic with decreased breath sounds bilaterally. However, he was alert and oriented. [pancreas.imedpub.com]

• Severe Clinical Course

  We found (a) that patients with image-proven pancreatitis suffer a more severe clinical course than those without; (b) that the sensitivity, positive predictive value, and accuracy in condition B are higher than in condition A at any cutoff level; (c) [ncbi.nlm.nih.gov]

• Abdominal Pain

  We describe 2 patients with diabetes mellitus, presenting with upper abdominal pain. Although imaging findings were consistent with acute pancreatitis (AP), serum amylase and lipase levels were within normal limits. [ncbi.nlm.nih.gov]

• Vomiting

  Three days later, the patient displayed sudden abdominal pain, distension, nausea, and vomiting without obvious inducements. [ncbi.nlm.nih.gov]

• Nausea

  Three days later, the patient displayed sudden abdominal pain, distension, nausea, and vomiting without obvious inducements. [ncbi.nlm.nih.gov]

  Nausea is a common symptom and can be due to pancreatic inflammation as well as slowing of the bowels. Effective intravenous medications are available for nausea. Pain and nausea will decrease as the inflammation resolves. [pancreasfoundation.org]

• Epigastric Pain

  I report a case of a 33-year-old woman, admitted with severe epigastric pain and vomiting 2 hours after an elective OGD for evaluation of chronic gastrointestinal symptoms. [ncbi.nlm.nih.gov]

  Causes constant, severe epigastric pain that classically radiates towards the back. www.medvizz.com #acutepancreatitis #pancreatitis #acutepancreatitispathology #acutepancreatitisusmle #acutepancreatitisosmosis #acutepancreatitisneetpg #acutepancreatitismbbs [youtube.com]

• Severe Abdominal Pain

  Acute pancreatitis arises suddenly and may be accompanied by severe abdominal pain. There are different types of pancreatitis, including mild, moderate or severe. [hopkinsmedicine.org]

  After performing initial laboratory tests and an abdominal CT scan, he was diagnosed with acute pancreatitis. However, he complained of severe abdominal pain and was drowsy 2 h later. [ncbi.nlm.nih.gov]

  Signs and symptoms include severe abdominal pain, nausea, vomiting, diarrhea, fever, and shock. Causes include alcohol consumption, presence of gallstones, trauma, and drugs. [icd10data.com]

  When to get medical help See a GP immediately if you suddenly develop severe abdominal pain. If this isn't possible, contact NHS 111 for advice. [nhs.uk]

  Advice for healthcare professionals: patients treated with DDP-4 inhibitors should be informed of the characteristic symptoms of acute pancreatitis – persistent, severe abdominal pain (sometimes radiating to the back) – and encouraged to tell their healthcare [gov.uk]

• Pancreatic Pain

  Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety. To assess the effectiveness and safety of opioids for treating acute pancreatitis pain. [ncbi.nlm.nih.gov]

  Morphine compared to metamizole for acute pancreatitis pain Morphine compared to metamizole for acute pancreatitis pain Patient or population: participants with acute pancreatitis pain Settings: Intervention: Morphine Comparison: Metamizole Improvements [doi.org]

  Opoids are commonly used to manage pain in acute pancreatitis but there are still some uncertainties about their clinical effectiveness and safety. Objectives: To assess the effectiveness and safety of opioids for treating acute pancreatitis pain. [cochrane.org]

  There is no benefit to using probiotics for acute pancreatitis. Pain Control Intravenous medications, typically potent narcotic pain medications, are effective in controlling pain associated with acute pancreatitis. [pancreasfoundation.org]

  Alternative techniques for pain control You’ll probably be given IV pain medication in the hospital. Alternative therapies may also help reduce pancreatitis pain. [healthline.com]

• Hypotension

  Systemic inflammation may lead to hypotensive shock which may lead to mortality. The early diagnosis of the disease and early medical interventions may prevent serious complications in acute pancreatitis. [symptoma.com]

  tachycardia → distributive shock Pancreatic necrosis : Uncorrected hypotension and third space loss → decreased organ perfusion → multiorgan dysfunction (mainly renal) and pancreatic necrosis Hypocalcemia : Lipase breaks down peripancreatic and mesenteric [amboss.com]

  […] may radiate to the back Nausea and vomiting Patients often have a history of prior similar episodes Signs Vital sign abnormalities dependent on stage of disease Early on may be normal or with slight tachycardia in response to pain Later in disease, hypotension [rebelem.com]

  Clinical findings Abdominal pain, nausea, vomiting, hypotension. Diagnosis Contrast-enhanced CT (method of choice), ultrasonography. Lab Increased amylase, increased lipase. Management Supportive bowel rest with parenteral nutrition. [medical-dictionary.thefreedictionary.com]

  CECT should be performed when there is a significant deterioration of the patient’s condition, including an acute drop in hemoglobin and hematocrit, tachycardia, and hypotension, an abrupt change in fever, or leukocytosis. [epomedicine.com]

• Tachycardia

  […] hypocalcemia References: [5] [6] [7] Clinical features Constant, severe epigastric pain Classically radiating towards the back Worse after meals and when supine Improves on leaning forwards Nausea, vomiting General physical examination Signs of shock : tachycardia [amboss.com]

  […] in response to pain Later in disease, hypotension, tachycardia and frank shock may develop Low grade fever common Epigastric tenderness with or without peritoneal signs Jaundice: indicates obstruction of common bile duct as etiology Hemorrhagic pancreatitis [rebelem.com]

  Other symptoms of acute pancreatitis include: feeling or being sick (vomiting) diarrhoea indigestion a high temperature of 38C or more (fever) yellowing of the skin and eyes (jaundice) tenderness or swelling of the tummy fast heartbeat (tachycardia) Eating [nhs.uk]

  […] food Nausea, emesis Retroperitoneal hemorrhage – indicates poorer prognosis Grey Turner sign – gray discoloration over flank Cullen sign – bruising in and around umbilicus Constitutional – fever Cardiopulmonary – respiratory distress, hypotension, and tachycardia [arupconsult.com]

  Common symptoms of acute pancreatitis can include: sudden severe upper abdominal pain (often referred to as epigastric pain) severe pain that might also be felt in the back nausea and vomiting diarrhea fever and chills racing of the heart (also known as tachycardia [ddc.musc.edu]

• Back Pain

  F-FDG PET/CT showed no definite malignancy but incidental finding of moderately severe acute pancreatitis, which was the cause of back pain. [ncbi.nlm.nih.gov]

• Grey Turner's Sign

  We report a case of retroperitoneal NSTI in an immunocompetent young male, with clinical symptoms and signs mimicking acute pancreatitis (pseudo-Cullen's and pseudo-Grey-Turner's signs. [ncbi.nlm.nih.gov]

  periumbilical ecchymosis and discoloration ( bluish-red ) Grey Turner's sign : flank ecchymosis with discoloration Fox's sign : ecchymosis over the inguinal ligament References: [1] [8] [9] Diagnostics Acute pancreatitis is diagnosed based on a typical [amboss.com]

  […] and symptoms Gastrointestinal Sudden upper abdominal pain – may radiate to back, flank, lower abdomen; worsened by ingestion of food Nausea, emesis Retroperitoneal hemorrhage – indicates poorer prognosis Grey Turner sign – gray discoloration over flank [arupconsult.com]

  (Rare) signs of hemorrhage on the physical exam include: Cullen sign : periumbilical bruising Grey-Turner sign : flank bruising There continues to be debate over the precipitating factor leading to acute pancreatitis, with duct occlusion being an important [radiopaedia.org]

• Confusion

  Massive bleeding from the IMV accompanied by shock bowel syndrome is a rare complication of acute pancreatitis that can be confused with arterial bleeding. [ncbi.nlm.nih.gov]

  An older person may only have problems with thinking, such as confusion hallucinations jumbled speech Seek care right away Seek care right away if you have kidney infection symptoms. [niddk.nih.gov]

  For example, mental confusion is common in older adults and is often their only symptom. People with chronic pyelonephritis may experience only mild symptoms or may even lack noticeable symptoms altogether. [healthline.com]

The following diagnostic tests are used to evaluate acute pancreatitis:

• Serum amylase: An increase in serum amylase level is always present with acute pancreatitis.
• Urine amylase: In the same way, amylase excretion in the urine is also evident.
• Serum lipase: An increase in serum lipase correlates well with the disease.
• Complete blood count: Demonstrates the acuteness of the disease while the neutrophil to lymphocyte ratio is valuable a predictor of pancreatitis prognosis.
• Serum electrolyte: Determines any instability in the electrolyte balance during the inflammatory process.
• Imaging methods like CT-scan, ultrasound and MRI can demonstrate the inflaming pancreas in the acute phase of the disease.

• Nephrolithiasis

  Loss-of-function mutations in CYP24A1 cause hypercalcemia, nephrolithiasis and nephrocalcinosis. We describe a woman with CYP24A1 deficiency and recurrent gestational hypercalcemia. [ncbi.nlm.nih.gov]

  50% 6 points Differential Diagnosis Acute cholecystitis Acute coronary syndromes Aortic dissection Appendicitis Cholangitis Diabetic ketoacidosis Ectopic pregnancy Gastric outlet obstruction Gastric volvulus Intestinal obstructions Mesenteric ischemia Nephrolithiasis [arupconsult.com]

  Additional predictors included nephrolithiasis in women and a history of recurrent AP in men. [jamanetwork.com]

  The severe pain and associated nausea and vomiting associated with nephrolithiasis can be mistaken for acute pancreatitis as well. Sharp, “tearing” pain that radiates to the back is pathognomonic of aortic dissection. [clinicaladvisor.com]

• Pancreatic Calcification

  Table 3 Imaging in acute pancreatitis Modality Pertinent findings Abdominal X-ray Ileus, loss of psoas shadow, sentinel loop, pancreatic calcification, and calcified gallstones Chest X-ray Pleural effusions (usually on left) and pulmonary infiltrates [academic.oup.com]

  […] of left diaphragm Plain Abdomina X-Ray (erect): To rule out perforated peptic ulcer Sentinel loop sign, Colon ‘cut-off’ sign, Renal halo sign May show gallstone, pancreatic calcification Abdominal USG: Can detect gallstones, biliary obstruction, pseudocyst [epomedicine.com]

  MRI also is limited in detecting gas and calcifications. [emedicine.com]

  Additionally, evidence of nephrolithiasis can sometimes be seen as well as foreign bodies or the telltale pancreatic calcifications of chronic pancreatitis. The liver size can often be estimated if hepatitis is considered. [clinicaladvisor.com]

• Hypertriglyceridemia

  Severe hypertriglyceridemia is the 3rd-leading cause of acute pancreatitis. [ncbi.nlm.nih.gov]

• Base Deficit

  […] on Ranson's 11 criteria : Ranson's Criteria On Admission Within 24-48 hours Age > 55 years HCT drops > 10% BUN increase by 5 mg/dL after resuscitation Serum Ca < 8mg/dL Arterial PaO 2 < 60mmHg > 6 L fluid deficit Base deficit > 4 mEq/L Note: amylase [medbullets.com]

  deficit – Fluid sequestration – PaO2 – AST = aspartate aminotransferase; BUN = blood urea nitrogen; PaO2 = partial arterial oxygen tension; WBC = white blood cell Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scale Equation includes [arupconsult.com]

  deficit > 4 Fluid sequestration > 6 L Mortality based on score < 3 = 1% 3-4 = 15% 5-6 = 40% > 6 = 100% Glasgow criteria or Imrie score On admission age > 55 years WCC > 16 glucose > 11 AST > 250 Within 48 hours decrease in HCT by > 10% increase in urea [lifeinthefastlane.com]

  Ranson’s criteria and Glasgow’s prognostic criteria are based on values obtained in the first 48 hours. [clinicaladvisor.com]

  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 [en.wikipedia.org]

• Amylase Increased

  Lab Increased amylase, increased lipase. Management Supportive bowel rest with parenteral nutrition. Prognotic instruments Ranson’s criteria, modified Glasgow criteria, APACHE II. [medical-dictionary.thefreedictionary.com]

• Lipase Increased

  […] of either pancreatic or salivary type amylase 11, 14, 15 and decreased clearance of amylase. 18 In contrast, lipase is a more sensitive and specific biomarker that is done as a single laboratory test for acute pancreatitis. 16, 19 - 21 Lipase increased [doi.org]

• Calcium Decreased

  Between one and three months postpartum, her serum calcium decreased from 11.4 to 10.2 mg/dL while her 1,25(OH) 2 D level decreased from 83 to 24 pg/mL. Her 24-hour urine calcium was 277 mg. Six months postpartum, she became pregnant again. [ncbi.nlm.nih.gov]

• Pancreatic Necrosis

  No relationship was found between the aetiology and the presence of pancreatic necrosis, EXPN, location of pancreatic necrosis or presence of collections. [ncbi.nlm.nih.gov]

  Pancreatic necrosis was defined as lack of enhancement of all or a portion of the gland. [doi.org]

  Pancreas The acute pancreatitis ( acute hemorrhagic pancreatic necrosis ) is characterized by acute inflammation and necrosis of pancreas parenchyma, focal enzyme necrosis of pancreatic fat and vessels necrosis - hemorrhage. [pathologyatlas.ro]

• Pleural Effusion

  She had an extended hospital course because of severe disease, characterised by systemic inflammatory response syndrome, pleural effusion and ascites but was successfully managed conservatively with bowel rest, hydration and pain management. [ncbi.nlm.nih.gov]

  Demonstration of a pleural effusion indicates severe disease. [academic.oup.com]

  The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the “traditional” multifactorial scoring systems: Ranson's, Acute [doi.org]

  Similarly, hepatic etiologies should be considered in those that present with ascites or pleural effusion. [clinicaladvisor.com]

The medical approach in the treatment of acute pancreatitis revolves on pain management with intravenous analgesics and bowel rest. Parenteral feeding or fluid maintenance may ensue for weeks till full recovery. A nasogastric tube (NGT) may be inserted for a week or two to drain the contents of the stomach especially with paralytic ileus.

The introduction of intravenous antibiotics may prevent necrosis if given early in the course. Surgical intervention may be imployed in the removal of gallstones or any blockage in the bile ducts that incites the disease. A cohort study was performed demonstrating that an early cholecystectomy in the first 48 hours shortens the clinical course of pancreatitis [9]. Fluid drainage of the pancreas may be performed in some cases to relieve inflammation.

Out of 100 cases of acute pancreatitis 10 to 15 cases die. Mortality cases are more pronounced in biliary pancreatitis compared to alcoholic ones. Acute pancreatitis patients who complicate with organ failures has a mortality rate of 30% [6].

However, in cases of pancreatitis with necrosis presenting with no organ failure mortality rate is almost zero. Majority of deaths in the first week of illness is due to multi-organ failure. Recent studies have demonstrated that an increased neutrophil-lymphocyte ratio (NLR) in the first 48 hours of the disease increases the likelihood of a severe pancreatitis attack carrying a grimmer prognosis [7].

Complications

The following disease conditions may complicate from acute pancreatitis:

• Recurrence: The pancreas may inflame again if the inciting factors aren’t dealt with accordingly.
• Acute renal failure: The kidneys are the most sensitive organ to hypotensive and hypovolemic shock.
• Acute respiratory distress syndrome (ARDS): The systemic inflammatory response may incapacitate the lung function and cause acute dyspnea.
• Heart Failure: Persistent shock may lead to cardiac pump overload and results to failure.
• Pancreatic cysts or abscess: The unabated exocrine auto-digestion may form abscess or cyst in the pancreatic parenchyma.
• Ascites: The irritation of the retroperitoneum from the inflammation may propagate extracellular fluid build-up in the abdominal cavity.
• Fungal superinfection: This may develop late in the clinical course [8].
• Hypotension: The systemic inflammatory response to acute pancreatitis dilates the vessels and cause a drop in blood pressure.

The most common cause of acute pancreatitis is gallstone formation that is lodged in the bile duct. Alcoholism is also a common cause of acute pancreatitis that could clinically resolve within two days. The less common causes of acute pancreatitis include infections, infestations, genetic defects and tumors of the pancreas.

Patients with celiac disease have a very high prevalence of acute pancreatitis due to pancreatic insufficiency [1]. Abdominal trauma and some elicit medications may trigger the inflammation of the pancreas in some cases.

In rare occasions, acute pancreatitis may be initiated after its inadvertent manipulation with some diagnostic procedures like endoscopic retrograde cholangio-pancreatography (ERCP) [2].

In the United States, approximately 40 cases of adult pancreatitis in 100,000 population per year is observed [3]. The incidence of acute pancreatitis worldwide is 5 to 80 per 100,000 population with the highest prevalence in Finland and the US [4]. Other European countries and Hong Kong has a predominance of gallstone pancreatitis compared to the alcoholic type observed in the US.

Alcohol related acute pancreatitis has a median age of onset at 39 years old while those cases related to the biliary tract has median age of 69 years old [5]. Patients suffering from AIDS may manifest pancreatitis early at a median age of 31 years old.

Males are more predisposed to acute pancreatitis than females due to alcohol related issues. The relative risk of African American for acute pancreatitis within the age group of 35 to 64 years is 10 times higher than any other age group risk in the United States.

The pathophysiology of acute pancreatitis is grossly due to the imbalance of the gland’s homeostasis or normal functioning. Common inciting factors like alcohol use, gallstones, and certain drugs injure the exocrine acinar cells of the pancreas and impair the secretion of zymogen granules.

Once the process of acute pancreatitis is triggered, lysosomal and zymogen granule compartments fuse which advertently activate the trypsinogen to trypsin that initiates autodigestion. The intracellular trypsin activates the entire zymogen cascade of events aggravating the autodigestive process. The molecular fragments formed from the secretory vesicles of the exocrine membranes attract inflammatory cells that further damage the organ.

The increase in early mediators in bloodstream like plasma tumor necrosis factor–alpha (TNF-a), interleukin 6 (IL-6), and interleukin 8 (IL-8) suggests that an inflammatory response triggered by the macrophages and activated neutrophils is in effect in acute pancreatitis. These same mediators cause an increase in vascular permeability in the pancreas which may lead to necrosis, edema and hemorrhage.

A systemic cascade of mediators and cytokines leads to complications like acute respiratory distress syndrome (ARDS), bacteremia, pleural effusion, gastrointestinal hemorrhage, and renal failure. Systemic inflammation may lead to hypotensive shock which may lead to mortality.

The early diagnosis of the disease and early medical interventions may prevent serious complications in acute pancreatitis. The early demonstration of gallstone in the biliary tree through imaging must be promptly performed to prevent pancreatitis. Pancreatic tumors and cysts must also be dealt with accordingly for the same purpose. Alcohol binge drinking must be avoided to prevent occurrence of the disease.

Acute pancreatitis is a clinical emergency defined as the sudden onset inflammation of the pancreas that may resolve in a few days. Inflammation of the pancreas may lead to auto-digestion of the organ.

The pancreas is a digestive organ found behind the stomach that secretes enzymes and aids in the digestion of carbohydrates, proteins and fats. It is also an endocrine organ that helps the regulation of plasma glucose by secreting the hormones insulin and glucagon. Acute pancreatitis may be managed medically without the need of surgery.

Acute pancreatitis is the sudden onset of inflammation of the pancreas. Proper education about the disease and how it is prevented to high risk individuals is of paramount importance. Patients who have just recovered from acute pancreatitis may tolerate low fat diet and clear liquids initially [10]. Avoidance of fatty foods and alcohol binges may lessen the risk of recurrence. Encourage them to inform their physicians about any abdominal trauma they may have incurred recently to avoid any risk in the future.

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2. Ito K, Fujita N, Kanno A, Matsubayashi H, Okaniwa S, Nakahara K, Suzuki K, Enohara R. Risk factors for post-ERCP pancreatitis in high risk patients who have undergone prophylactic pancreatic duct stenting: a multicenter retrospective study. Intern Med. 2011; 50(24):2927-32 
3. Granger J, Remick D. Acute pancreatitis: models, markers, and mediators. Shock. Dec 2005;24 Suppl 1:45-51.
4. Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc. Dec 2002;56(6 Suppl):S226-30.
5. Morinville VD, Barmada MM, Lowe ME. Increasing incidence of acute pancreatitis at an American pediatric tertiary care center: is greater awareness among physicians responsible?. Pancreas. Jan 2010;39(1):5-8.
6. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. May 18 2006;354(20):2142-50.
7. Suppiah A, Malde D, Arab T, Hamed M, Allgar V, Smith AM, et al. The Prognostic Value of the Neutrophil-Lymphocyte Ratio (NLR) in Acute Pancreatitis: Identification of an Optimal NLR. J Gastrointest Surg. Feb 1 2013;
8. Maraví-Poma E, Gener J, Alvarez-Lerma F, Olaechea P, Blanco A, Domínguez-Muñoz JE. Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin. Intensive Care Med. Nov 2003;29(11):1974-80.
9. Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. Apr 2010;251(4):615-9.
10. Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin Gastroenterol Hepatol. Aug 2007;5(8):946-51; quiz 886.