












































PB 27JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

Original Article

Comparison of clinical course of Acute Biliary and Non-
Biliary   Pancreatitis
Abishek  Bhattarai1 , Pragya Devkota2 , Bishnu Prasad Kandel3 , Bikal Ghimire3 , Prasan Bir Singh Kansakar3, 
Ramesh Singh Bhandari3 , Kishor Kumar Tamrakar4 , Palaswan Joshi Lakhey3, Parshuram Mishra 3, Yogendra 
Prasad Singh3, Pradeep Vaidya3 , Keshaw Prasad Singh3

 1Department of Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal

2Resident, Department of Pharmacology, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal

3Department of Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal

4Chitawan Medical College, Bharatpur Chitawan 

Correspondence: Dr Abhishek Bhattarai, Department of Surgery, Maharajgunj Medical Campus, Tribhuvan University 
Teaching Hospital

Email: abhishekbhattarai@gmail.com

Abstract

Introduction:  Incidence of acute pancreatitis (AP) varies in different parts of the world. The 
published data are mainly based on retrospective analysis of hospital admissions, which show 
that there are considerable geographical differences in the incidence rate. There are also regional 
divergences with regard to the etiology, and its impact on morbidity and mortality. Therefore, we 
compare the clinical course of acute biliary and non-biliary pancreatitis at the Tribhuvan University 
Teaching Hospital (TUTH) as well as we compare the morbidity and mortality and duration of 
hospital stay in these groups.

Methods: This prospective study included the patients with a diagnosis of AP over a period of 
one year. Eighty-five patients with the diagnosis of AP were included in the study. Revised Atlanta 
classification system (2012) was used to diagnose and define the severity of disease. The occurrence 
of local and systemic complications, median duration of hospital stay and mortality in AP was studied.

Results: Among 85 patients, 34 patients were females and 51 were males. Among them, 46 patients 
belonged to the biliary group and 39 belonged to the non-biliary group. Alcohol intake was the major 
etiology in the non-biliary group (n = 26) and all of them were male. The majority of the gallstone 
induced AP patients were female (n = 29). Twenty-nine patients developed severe acute pancreatitis 
(SAP: 16 in biliary and 13 patients in non-biliary group). Complications were mostly seen in SAP. 
The acute fluid collection was the most common local complication (15 patients in biliary and 15 
patients in non-biliary group, p > 0.05) and respiratory failure was the most common systemic 
complication (18 patients in biliary and 16 patients in non-biliary group, p > 0.05) in both groups. 
Three patients in biliary group and four patients in non-biliary group died due to multi-organ failure 
(p > 0.05). There was no statistical significant difference in the median duration of hospital stay in 
these groups.

Conclusion: Though pathogenesis vary for different etiologies, once the disease process has started, 
local complications, systemic complications, duration of hospital stay and mortality in AP depends 
on the severity of the disease irrespective of the etiology.

Key words:  Acute Pancreatitis; Biliary Pancreatitis; Non-Biliary Pancreatitis.



28 29JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

Introduction

Acute pancreatitis (AP) is a common cause of acute 
abdomen with variable risk factors, and wide range of 
severity from mild self-limiting disease to a severe rapidly 
progressive illness leading to multi organ failure and 
death.1 About 15-20% of the patients with a history of AP 
can progress to severe acute pancreatitis associated with 
local and systemic complications.2 There are no actual 
prevalence data available in our country. However hospital 
based data showed an annual incidence of 60 to 90 patients 
per year at tertiary care center in Kathmandu. 3, 4

Two major etiological factors responsible for AP are 
gallstone and alcohol. 5 Other risk factors include endoscopic 
retrograde cholangiopancreatography (ERCP), trauma, 
drugs, surgery, malignancy, viral infection, hyperlipidemia, 
and biliary tract anomalies.1 Idiopathic pancreatitis (IP) is 
described  as pancreatitis in which the etiological factor 
cannot be diagnosed.6 The incidence of IP ranges from 4.21 
per 100 000 to as high as 45.33 per 100 000.6

There was no universally accepted definition, classification 
and severity grading of the AP in the past. Atlanta 
symposium was first convened in 1992 attempted to 
provide the common terminology and define the severity 
of the disease with a uniform classification for the first time 
and it was revised & updated in 2012. This new definition 
and classification system addresses the diagnosis, types 
and severity of AP, and definition of pancreatic and peri-
pancreatic collections.7 

In spite of numerous advances in diagnosis and treatment 
of AP in the recent years, ability to predict outcome remains 
challenging. Several scoring systems have been proposed 
for the assessment of the severity, including Ranson score, 
Glasgow score, BISAP score and APACHE, SIRS score 
by different authors to predict the severity and outcome 
following AP.8 None of them are accurate to predict 
morbidity and mortality.

Generally, it is believed that, though the pathogenesis is 
different for different etiology, once the disease process has 
started mortality depends on the severity of the disease. 
There are several publications regarding the impact of 
etiology on the outcome of the AP. The published data 
are mainly based on retrospective analysis of hospital 
admissions, which showed that there are considerable 
geographical differences in the incidence rate as well as 
etiology, and its impact on morbidity and mortality. Some 
authors deny a relationship of mortality and morbidity with 
etiology whereas others describe the relation.9-17 Therefore, 

we compare the clinical course of acute biliary and non-
biliary pancreatitis at the Tribhuvan University Teaching 
Hospital (TUTH) as well as we compare the morbidity, 
duration of hospital stay and mortality in these groups so 
that we could detect difference in characteristics that could 
be relevant for the prognosis and therapy.

Methods

Patients with a diagnosis of AP admitted in the surgical ward 
of Tribhuvan University Teaching Hospital over a period of 
one year (2070/05/01 to 2071/04/30) were studied. Patients 
of age less than 18 years, post ERCP pancreatitis, recurrent 
acute pancreatitis were excluded. Diagnosis of acute 
pancreatitis, its severity, local and systemic complications 
were defined as per revised Atlanta classification 2012. 
Modified Marshall Score was determined at admission, and 
at 48 hours of hospital admission.

Biliary etiology was confirmed as the cause of AP in patients 
with a history of cholecystectomy or with CBD exploration 
or detection of gall bladder of bile duct stone on imaging. 
Combination of age, sex and laboratory markers (system 4) 
was used in case of difficulty to predict a biliary etiology. 18

Alcoholic etiology was defined on the basis of a history 
of chronic alcohol intake or recent alcohol intake in the 
week prior to admission while AP of other etiologies were 
excluded. 15, 19

Other etiologies were diagnosed on the basis of the history 
and examination of the patients. When a diagnosis could 
not be made through a history, physical examination, 
laboratory studies, and imaging modalities those cases 
were designated as idiopathic pancreatitis.

The data were analyzed using Statistical Package for Social 
Sciences (SPSS) for Windows version 19. Chi square test 
was used for categorical variables, and t-test was used 
for continuous variables. P-value <0.05 was considered 
clinically significant.

Result

Within the study period, a total of eighty five patients 
were included in the study. Forty six (54%) patients were 
admitted with biliary etiology and 39 (46%) with non-
biliary etiology. (Table 11) Among non-biliary patients, 
alcohol induced pancreatitis was the most common (n=26). 
In 5% of the cases etiology could not be identified (n=4).



28 29JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

Table 1: Etiology of acute pancreatitis

Total No. of pts.  n=85

Biliary 46 (54%)

Non biliary 39 (46%)

                 Alcohol 26 (31%)

                 Drug induced 3 (3.5%)

                 Trauma 3 (3.5%)    

                 Malignancy 2 (2%)

                 Mumps 1 (1%)

                 Others 4(5%)

Age and gender

The age of the patients ranged from 21 to 85 years. The mean 
age was 46.15 ± 15.75 years for biliary and 40.23±15.65 years 
for non-biliary group (P value >0.05). Biliary pancreatitis was 
predominantly seen in female (n = 29), whereas non biliary 
was mostly seen in male (n=34). (Table 2)

Table 2: Age and gender distribution of the patients

Biliary 
(n = 46)

Non biliary
  (n = 39)

 p value

Male 17 (37%) 34 (87%) 0.001
Female 29 (63%) 5 (13%) 0.001
Mean age 
(year)

46.15±15.75 40.23±15.65 0.087

Severity

About 53% of the patients belonged to the mild group, 13.0 
% in moderate group and 34.0% in severe group. There was 
no statistical difference in the incidence of severity among 
the biliary and non-biliary groups. (Table 3)

Table 3: Distribution of patients, according to severity

Severity Biliary 
(n = 46)

Non biliary
 (n = 39)

Total 

Mild (52.94%) 26 (56.5%) 19 (48.7%) 45

Moderate 
(12.94%)

4 (8.6%) 7 (17.9%) 11

Severe 
(34.11%)

16 (34.7%) 13 (33.3%) 29

Total 46 39 85

Patients with MAP had a median duration of hospital stay 
of 4 days (range of 4-6 days for biliary and 4-5 days for 
non-biliary group). Whereas in moderate group it was 6 
days (6-9 days) for biliary and 7 days (6-17days) for non- 
biliary group. For severe group it was 10 (9-60) days for 
biliary and 13 (7-30) days for non-biliary pancreatitis.

Diagnostic criteria   

Twenty nine out of forty six (63.0%) in biliary group and 
22 out of 39 (56.4%) had a history of a typical pancreatic 
type of pain. The pancreatic enzymes amylase and lipase 
were significantly raised in both groups. Whereas USG 
was less reliable to diagnose acute pancreatitis during an 
emergency. (Table 4)

Table 4: Diagnostic criteria of AP

Biliary 
(n = 46)

Non biliary
(n =39)

p value 

Typical pain 29 (63%) 22 (56.4%) 0.534

Raised amylase /lipase 38 (82.6%) 35 (87.7%) 0.533

USG 16 (34.7%) 14 (35.8%) 0.914

Local complications

Fifteen (32.60%) out of 46 patients in biliary group and 15 
out of 39 (38.46%) patients in non-biliary group developed 
local complications. Eleven patients (23.91%) in biliary 
group and 8 patients (20.51%) in non-biliary group 
developed pancreatic necrosis (p value >0.05). (Table 
5) There was no statistical difference in the incidence of 
peri-pancreatic collection, infected and sterile pancreatic 
necrosis, pancreatico- peritoneal fistula and vascular 
aneurysm  in biliary and non-biliary groups. 

Table 5: Incidence of local complications in Biliary and 
Non-biliary pancreatitis 

Local Complications Biliary 
(n = 46)

Non biliary 
(n = 39)

p value 

Acute fluid collection 15 (32.6%) 15 (38.4%) 0.574

Necrosis 11 (23.9) 8 (20.5%) 0.233

      Sterile 7 (15.2%) 7 (17.9%) 0.753

      Infected 4 (8.6%) 1 (2.5%) 0.231

 Pseudo aneurysm 1 (2.1%) 0 0.231

Pancreatico-peritoneal 
fistula 

1 (2.1%) 3 (7.6%) 0.231



30 31JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

Systemic complications 

Respiratory failure was the most common organ failure 
followed by renal and cardiovascular failures with the 
similar incidence rate (p value  >0.05) in both groups. 
(Table 6) 

Table 6: Incidence of systemic complications in Biliary 
and Non biliary pancreatitis

 Biliary 
(n = 46)

 Non 
biliary 
(n = 39)

 p 
value 

Cardiovascular failure  6 (13%)  4 (10.2%)  0.691

Renal failure  6 (13%)  4 (10.2%)  0.691

Respiratory failure  16 (34.7%)  16 (41%)  0.554

Transient organ failure  2 (4.3%)   4 (10.2%)  0.289

Persistant organ failure 16 (34.7%)  13(33.3%)  0.915

Single organ failure  9 (19.5%)  11 (28.2%)  0.349

Multi organ failure  9 (19.5%)  6 (15.3%)  0.614

Similarly, there was no statistical difference in the incidence 
of other complications like pleural effusion, chest infection, 
however, there is a higher proportion of cholangitis and 
cholecystitis in biliary group, whereas, variceal bleeding 
and stress ulcer in  non biliary group (table: 7).

Table 7: Incidence of other complications in Biliary and 
Non biliary pancreatitis

Complications 
Biliary 
n=46

Non biliary
n=39

 p value 

Pleural effusion 20 (43.4%) 18 (46.1%) 0.805
Chest Infection 11 (23.9%) 7 (17.9%) 0.502
Stress ulcer 0 3 (7.6%) 0.055
Variceal bleed 0 3 (7.6%) 0.055

Cholangitis 6 (13%) 0 0.80

Cholecystitis 4 (8.6%) 0 0.231

Diabetes 6 (13%) 3 (7.6%) 0.424

Intervention 

Some form of intervention was done in 3 patients with 

biliary etiology and 4 patients with non-biliary etiology. 
Necrosectomy, percutaneous drainage and PTBD were 
done for one patient in each group, whereas ERCP and 
stenting was done in one patient with alcoholic pancreatitis 
with pancreatic ascites. (P value >0.05) (Table 8)

Table 8: Total no. of Interventions done in Biliary and 
Non biliary pancreatitis

 Biliary
(n =46)

 Non biliary 
(n=39)

 p value 

 Necrosectomy  1  1  0.906

 Percutaneous 
drainage 

 1  1  0.906

 PTBD  1  1  0.906

 ERCP + stenting  0  1  0.275

Total  3(6.52%)  4(10.25%)

Mortality 

Three patients in biliary group and four patients in the non-
biliary group died due to MODS. (P value >0.05)

Discussion

Worldwide biliary and alcohol are the most common 
etiologies of pancreatitis. These account for almost 80% 
of the cases of acute pancreatitis. 20 But their incidence 
varies in  different parts of the world. But their incidence 
varies in different parts of the world. Some of the  Hospital-
based studies from Australia, America and India showed 
that incidence of non-biliary pancreatitis is more common 
than that of biliary pancreatitis in their institute, whereas, 
from Nepal, it showed a higher incidence of the biliary 
pancreatitis than non-biliary pancreatitis. 3, 4, 20 21 22 In 
our study, incidence of biliary pancreatitis is higher than 
that of non -biliary pancreatitis. The exact cause of this 
geographical variation is not well known, but growing 
evidence suggests that environmental and possibly genetic 
cofactors may also play a role in the development of AP.

In the present study, it was found that AP is more common 
in males than females and can affect any age, which is 
comparable with other studies. 23 It was also found that 
alcohol was the main etiology in non-biliary pancreatitis and 
all alcoholic pancreatitis were seen in male patients, while 
biliary pathology was the main cause of AP in females. It 
is due to hormonal influence, especially estrogen, which 
plays an important role in gallstone formation in females, 
hence increases the risk of pancreatitis. 23



30 31JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

MAP accounts more than 50% of the cases in most of 
the literature, but there is a wide range of variation in 
the incidence of MSAP ( ranges from 25.39% to 35.6%)  
and SAP ( ranges from 4% to 25.39%) respectively. 21, 24, 
25 In this study, there was a higher incidence of SAP in 
both groups, as compared to other study, because most 
of the severe cases were referred cases from primary and 
secondary health care centers. The result we obtained also 
did not match  with the result obtained from another tertiary 
care center from Kathmandu with a higher proportion of 
severe acute pancreatitis in both groups3.

Literature shows 30-57% of patients with AP have fluid 
collections with 39% of the patients having  two areas 
involved and 33% having three or more and about 5–21% 
of patients develop necrosis of the pancreatic parenchyma 
or peri-pancreatic tissue or both.7, 21, 26  Up to 30% of 
patients with necrotizing pancreatitis develop infection 
and its incidence may increase to 70% in the third week. 
2 In our study, the incidence of acute fluid collection was 
32.60% and 38.46% and incidence of necrosis was 23.91% 
and 20.51% in biliary and non-biliary group and there was 
no statistical difference in the incidence of infective and 
non-infective local complications in between these groups, 
which is also comparable with the data in the published 
literature. However, some of the studies also show that 
alcoholic pancreatitis tends to have more prominent 
peripancreatic changes than biliary pancreatitis, and higher 
incidence of necrotizing pancreatitis.11, 27

Hemorrhagic complications are frequently encountered 
in routine practice following AP. The incidence of fatal 
haemorrhagic complications accounts for 1.2-14.5% and 
incidence of pseudoaneurysm is about 3.5-10%.28

In our study there was a patient with pseudoaneurysm of 
gastroduodenal artery with infected pancreatic necrosis 
in biliary group, causing massive bleeding, which was 
managed with laparotomy, necrosectomy and suture 
ligation of GDA, later patient devlop colocutaneous fistula.

 Pancreatic ascites or pancreatico peritoneal fistulas are 
the rare complications of acute pancreatitis.29 These are 
mostly seen in the patients with traumatic, chronic and 
alcohol induced pancreatitis, cystic duplications of bilio-
pancreatic ducts, ampullary stenosis or ductal lithiasis. 30, 31  
All together 4 patients developed pancreatic ascites in our 
study, one in biliary and 3 in non-biliary group. Incidence 
of local complications in our study is comparable with that 
of others in the literature.

Pulmonary dysfunction was the most important systemic 
manifestation  of acute pancreatitis ranging from hypoxia to 

ARDS. 32, 33 It is seen in 30-50% of the patients with severe 
pancreatitis and is regarded as one of the major factors 
of mortality in 22-25% of the patients and a contributing 
factor in an additional 30% morbidity during the course of 
disease.33 It is because lung involvement is the integral part 
of (third phage) of the AP characterized by progression of 
the pancreatic injury and involvement of extrapancreatic 
change including SIRS and ARDS. These complications 
are due to production of noxious cytokines, leading to 
increased lung capillary permeability and decreased level 
of lung surfactant. 32  Respiratory dysfunction precedes 
heart, liver and kidney failure and is responsible for the 
early deaths in severe pancreatitis. 

The prevalence of acute renal failure (ARF) in AP ranges 
from 6-16% and carries a bad prognosis, especially in 
elderly and in those with multi-organ failure in presence of 
local complications.34, 35 Similar to a respiratory dysfunction 
ARF is due to toxic injury to the kidney by release of 
variety of vasoactive peptides, enzymes, cytokines and 
other inflammatory mediators from the necrosed pancareas. 
Hypovolemia, decreased renal blood flow, intravascular 
clotting and infection also contributes to ARF35.

The mechanism of circulatory failure is poorly understood 
in AP. Failure in the physiological equilibrium between 
vasodilator (e.g. nitric oxide) and vasoconstrictor 
(endothelin and angiotensin) mediators have been 
proposed.36

 Respiratory failure was the most common systemic 
complication in our study and there was also no significant 
difference in the incidence of systemic complications in 
both biliary and non-biliary groups, but there was some 
variation in the incidence systemic complications as 
compared with other studies.21  

The need of intervention depends on the type of 
complications that develops after an episode of AP. Overall 
12.8% AP patients required intervention. For MSAP and 
SAP this was 12.3% and 38.5% respectively. 21 In this 
study, intervention was required only in SAP. For biliary 
etiology it was 6.52% and for non-biliary it was 10.25%.
The overall incidence of mortality is 5%.37 But this also 
depends on the type and severity of the disease. For MSAP 
mortality is < 8%, whereas for SAP it can go up to 62%.37, 
38 Mortality is directly proportional to the incidence of 
infective complications.37 In present study mortality 
rate was 6.52% and 10.25% for biliary and non-biliary 
etiologies respectively, and there was no mortality in mild 
and moderate group.



32 33JSSN JSSNJournal of Society of Surgeons of Nepal Journal of Society of Surgeons of Nepal

JSSN 2017; 20 (1) JSSN 2017; 20 (1)

Duration of hospital stay varied according to the severity 
of the disease. There was difference in the median duration 
of hospital stay among MAP, MSAP and SAP group.4, 21 In 
our study there was no significant difference in length of 
hospital stay in between the biliary and non-biliary groups. 
But as compare with the similar kind of  study, there was 
a significant difference in the median duration of hospital 
stay in the severe group which is 24 (16-39) days, this is 
because of less number of interventions done in SAP in 
our study.21

Conclusion

Though pathogenesis vary for different etiologies, once the 
disease process has started, local complications, systemic 
complications, duration of hospital stay and mortality in AP 
depends on the severity of the disease irrespective of the 
etiology.

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