Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad Zakaur Rab Siddiqui et al

Original Article

Zakaur Rab Siddiqui*

Presentation and Outcome of Acute Aatif Inam**
Muhammad Saaiq***
Pancreatitis at Pakistan Institute of Niaz-ud-din****
Muhammad Zaheer*****
Medical Sciences, Islamabad Shabana Jamal******
Tanwir Khaliq*******
Syed Aslam Shah********
Background and Objectives: Acute pancreatitis is an important cause of abdominal
pain that may be associated with significant morbidity for the patient and considerable * Postgraduate Trainee
workload for the hospital. Our impression has been that it is becoming increasingly ** Assistant Professor
common, perhaps in tandem with Westernized lifestyle or other unknown causes. The study *** Senior Registrar
**** Postgraduate Trainee
aimed to enlist the various presentations of acute pancreatitis, assess the severity of the
***** Senior Registrar
disease by employing Ranson’s criteria and pattern of outcome in terms of duration of ****** Assistant Professor
hospital stay, morbidity and mortality in our set up. ******* Associate Professor
Study Design: Descriptive study. ******** Professor and Head,
Place and Duration of Study: Department of surgery, Pakistan Institute of Medical Department of General Surgery,
Pakistan Institute of Medical Sciences
Sciences (PIMS), Islamabad from January 01, 2006 to December 31, 2006.
(PIMS), Islamabad.
Patients and Method: All patients presenting with signs and symptoms of acute
pancreatitis and raised amylase level (greater than 5 times normal) in the period of study
were included in the study. The data of 107 consecutive patients admitted with the
diagnosis of acute pancreatitis were collected through a pro forma and assessed with
reference to clinical presentation, etiological factors, severity (using Ranson’s score),
length of hospital stay, surgical intervention if any and outcome in each case.
Results: Out of 107 patients, there was male predominance with a male: female of 1.1:1.
The mean age was 44 + 17 years with a range of 11-88 years. Eighty-six (80%) patients
presented in emergency with pain, nausea and vomiting as the main symptoms. In 50
cases(46.7%), the etiology remained unknown while in the remaining cases the most
common aetiological factor for acute pancreatitis was gallstones i.e. in 39 cases (36.45%)
followed by alcohol in 12 cases (11.2%). The severity of the disease based on Ranson score
was < 3 in 50 (46.7%), 3 in 19 (17.8%) and > 3 in 38 (35.5%) patients. The average length of
stay was 8.91+7.3 days and the mortality was 8.4% but the morbidity remained high with the
sequelae of resolution in > 50% cases. Address for Correspondence:
Conclusion: Acute pancreatitis shows a comparable frequency in our set up when Dr. Zakaur Rab Siddiqui,
Postgraduate Trainee,
compared to the world literature. However when compared with etiology and presentation,
Department of Surgery,
the gallstones rather than alcohol constitute the main cause in our setup. Meanwhile due to Pakistan Institute of Medical Sciences
adoption of Western way of life, the incidence seems to be increasing. (PIMS), Islamabad.
Key Words: Acute Pancreatitis, Gallstones, Ranson’s score. E-mail: drzaka2003@yahoo.com

Nearly 25% of all attacks of pancreatitis have severe

Introduction
Acute Pancreatitis is a common disorder
with potentially devastating consequences. It is a
multifaceted disease with multiple etiologies and there
is a wide variability in the presentation and clinical
course of the disease.1-3 The incidence of acute
pancreatitis is known to differ geographically due to
differences in alcohol consumption or in the incidence
of gallstones disease in different parts of the world.4-6
complications and the death rate of clearly diagnosed
cases has remained high at 10-25% over the past
few years.7 Most studies on acute pancreatitis are
based on the Western population.8, 9 It is generally
perceived that acute pancreatitis runs a benign course
in Asian countries and the etiology is different from that
of the Western population.
There is very little information in literature
describing etiology and clinical outcome of acute
pancreatitis in our population. This study was

Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 67

Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad Zakaur Rab Siddiqui et al

undertaken to describe the demographic, etiological and Eighty-six (80%) patients presented in emergency with
clinical course of acute pancreatitis in our setup. pain, nausea and vomiting as the main symptoms.
Gallstones were identified as the predominant factor
associated with acute pancreatitis and was noted
Patients and Methods
The study was conducted at Department
Table No. I: Ranson’s Score of the Patients
of surgery, Pakistan Institute of Medical Sciences
(PIMS), Islamabad. It was a prospective study of Score Frequency Percentage
107 consecutive admissions for acute pancreatitis (n=107)
from January 2006 to December 2006. The diagnosis
of acute pancreatitis was accepted when a compatible 0-2 50 46.7 %
clinical picture was associated with raised serum
amylase of more than five times the normal value. 3 19 17.8 %
Evidence from laparotomy was also accepted for
the diagnosis. Ultrasonography was routinely 4-5 28 26.2 %
performed for all patients diagnosed to have acute
pancreatitis and contrast dynamic computerized >5 10 9.5 %
tomography scan was performed on patients judged to
have severe disease.
Alcohol was considered the etiology when Table No. II: Duration of Hospital Stay in
patient volunteered a history of a recent binge Patients with Acute Pancreatitis
of alcohol or reported a regular intake. Gallstone
related disease was based on identification of
gallstones by ultrasound, endoscopic retrograde Duration No. of Patients Percentage
cholangiopancreatograpy (ERCP) or CT scan. (n=107)
Traumatic pancreatitis was diagnosed if the disease
occurred after an episode of trauma. The etiology was 0 Days 03 2.8 %
considered to be unknown when no identifiable factor
Upto 1 week 54 50.6 %
could be found. The severity of acute pancreatitis was
stratified using the Ranson’s score. The disease was 1-2 weeks 35 32.7 %
considered severe when the Ranson’s score was 3 or
greater. Aggressive treatment in an intensive care or a > 2 weeks 15 14.0 %
high dependency unit was instituted if a diagnosis of
severe acute pancreatitis was made. All complications
were managed with appropriate surgical approaches.
All the patients having pancreatitis secondary to
Table No. III: Complications associated
gallstones underwent cholecystectomy either during with Severe Disease
same admission or after some interval. (n=27)
The data were analyzed through SPSS version
13 and descriptive statistics were used to calculate
Peripancreatic fluid collection 20
frequencies, ratios, percentages, means and standard
deviation. Pancreatic pseudocyst 04

Results
The 107 consecutive admissions occurred
for acute pancreatitis during the period of study.
Fourteen patients had recurrent admissions for
recurrent attacks of pancreatitis, of which 9 were
secondary to the biliary cause. The mean age of the
patients was 44 years (SD ± 17 years) with the range of
11 to 88 years. There were 56 males and 51 females
(M: F = 1.1:1). The sex difference seen among
the patient was not statistically significant (p > 0.05).
Pancreatic abscess 01
Pancreatic necrosis 02
in 39 patients (36.45%) of which 4 of the patients
had dilated common bile duct with stones. Twelve
patients (11.2%) were diagnosed to have pancreatitis
secondary to alcohol. Other factors identified in
6 patients included trauma in four patients (3.74%),
hyperlipidaemia in one patient (0.9 %) and carcinoma
pancreas in one patient (0.9%). In 50 patients (46.7%),

Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70 68

Presentation and Outcome of Acute Pancreatitis at PIMS, Islamabad
no known factors could be identified. Gallstone
pancreatitis was predominantly a disease of the
female i.e. 27 out of 51 (53.0%). Table I shows
Ranson’s score of the patient. The average length of
stay was 8.91 + 7.3 days (Table II). Twenty-seven
patients manifested with local complications in the
form of peri-pancreatic collection, pseudocyst, necrosis
or abscess (Table III). There were 9 deaths, giving a
mortality rate of 8.4 % and all occurred in patients with
severe disease.
Discussion
Acute pancreatitis is a protean disease,
capable of wide clinical variation ranging from a
mild, self limiting disease to a severe disease with
devastating consequences.2
Although there are various factors capable of
precipitating acute pancreatitis, biliary lithiasis and
alcohol together account for upto 80% of the
disease.1, 2 Gallstones have been recognized to be the
predominant factor responsible for acute pancreatitis,
representing 40 % to 60 %.4, 5, 10-12 However more
recent reports suggest alcohol as the most common
etiological factor6, especially in the West. Alcohol as an
etiology was uncommon in Pakistan as religion prohibits
Muslims from consuming alcohol.
In our study gallstones were identified as the
most important etiologic factor associated with acute
pancreatitis, accounting for 36.5% of the cases.
Alcohol related pancreatitis was observed in 11.2% of
the cases. A similar observation was made by Zahra F
et al10 and Asifi M et al11 in their studies performed at
Sri Ganga Ram Hospital and Mayo Hospital Lahore,
respectively in which they found cholelithiasis as a
predominant cause.
Several studies have shown that biliary sludge
can be detected in many patients labelled as “idiopathic”
pancreatitis.13, 14 It is important to be thorough with
investigations in this group of patients and repeat
examination may increase the proportion with an
identified etiology.
Mahendra RS et al8 and Kandasami P et al9,
could not establish the etiology in most of the
cases. Mahendra RS et al8 noted abnormal serum
transaminase levels in 35% of the cases and concluded
the possibility of biliary microliths as a possible cause.
It may be postulated that microliths and
biliary sludge may also be a problem with our
population in Pakistan. The most effective plan of
treatment for acute pancreatitis is aimed at identifying
the mechanism responsible for its development. The
investigation into the etiology of acute pancreatitis in our
community will have to include more sensitive tools
like Endoscopic retrograde cholangiopancreatography
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 67-70
Zakaur Rab Siddiqui et al
(ERCP), endoscopic ultrasonography or magnetic
resonance cholangiography.
Severe disease is characterized by organ failure
and / or local complications such as necrosis,
pseudocyst or abscess and 95% of deaths will occur
in this subset.1, 15
In our study a significant number of
patients (25.2%) developed organ dysfunction or local
complications. The characteristics of acute pancreatitis
in the patients studied were not different when
compared to the West with regards to the severity of the
disease and the nature of complications.12-13
The precise mortality rate from acute
pancreatitis is difficult to ascertain due to variations in
diagnostic threshold and inconsistent use of autopsy
data. It is generally reported that the overall mortality of
acute pancreatitis is 5-10% and may increase to 35% or
higher if complications develop.7, 13, 15, 16
The mortality rate of 8.4% in our study is
comparable with other reports from the West13, 17,
where the mortality rate is in the range of 2-9%
for all cases of acute pancreatitis, but lower than
those observed by Taj A et al (20%)18 and Mirza SM
et al (21.2%)19 which may be due to our protocol to
admit every patient with severe acute pancreatitis in
intensive care/high dependency unit; however it is
relevant to recognize that there are many confounding
factors, including the age of the patient, coexisting
medical problems, amount of pancreatic necrosis and
infection of the pancreatic necrosis.
Conclusion
Acute pancreatitis shows a comparable
frequency in our set up when compared to the world
literature. However when compared with etiology and
presentation, the gallstones rather than alcohol
constitute the main cause in our setup. Meanwhile due
to adoption of Western way of life, the incidence seems
to be increasing.
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