The management of severe acute pancreatitis 33

severe pain and who were sufficiently ill to require at least gastro-intestinal decompression and intravenous fluid therapy. In them the initial diagnosis of pancreatitis was made on the clinical picture supported by a serum amylase exceeding 300 Somogyi or Pimstone units (182 cases) and/or clear evidence of acute haemorrhagic or oedematous disease at surgery (112 cases) and/or at autopsy (twenty-one cases). It should be noted that cases classified as mild to moderate or chronic (Table 1) have not been included in this review even though 30% of them gave a history of undoubted acute attacks prior to 1960. During the period 1960-65 the patients in the mild to moderate group presented with attacks of pain which often required analgesics and even hospitalization but they were not very ill and did not require intravenous therapy and/or gastrointestinal decompression while those in the chronic group presented with pancreatic dysfunction with or without pain. We have also classified our cases on an etiological basis because, although the initial treatment of the acute attack is the same for all etiological types, the severity of the attack and the subsequent course and management of the disease depend largely upon the cause (Howard & Ehrlich, 1960; Louw, Marks & Bank, 1963; Marks & Bank, 1963). We have subdivided our cases into four main etiological groups (Table 1) and their distribution in the series as a whole (as well as in the severe acute group) was as follows: alcoholic 59%, biliary 17%, miscellaneous 16% and idiopathic 8%. Our series differs from most others in the preponderance of alcoholic pancreatitis which in most parts of the world accounts for only 10-20% of all cases and this is probably due to the ready availability of cheap wines and the drinking habits of our labouring class. Because of the frequency of alcoholic pancreatitis, biliary pancreatitis comprised a smaller proportion of the total than the usual 30-60 %. It should also be noted that those with acute biliary pancreatitis included thirty-six adults with stones, seven children with ascariasis, one patient with a choledochal cyst and one with a perivaterian diverticulum. The miscellaneous group includes a great variety of rarer etiological types and from Table 2, which reflects the various causes of acute attacks only, it should be evident how extensive the search should be to determine the cause of the condition. The idiopathic group consists of cases in whom we have been unable to find a cause. Although the incidence of acute attacks was