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==Background==

[[File:Blausen 0699 PancreasAnatomy2.png|thumb|Pancreatic anatomy]]
*Acute inflammatory process that may involve surrounding tissue and remote organ systems<ref name="NEJM> Whitcomb D. Acute Pancreatitis. N Engl J Med 2006; 354:2142-215</ref>
*Disease can range from mild inflammation to severe necrosis and multi-organ failure

===Etiology===

*[[Special:MyLanguage/Symptomatic Cholelithiasis|Gallstones]] (including microlithiasis) - 35-40% of cases in most parts of the world <ref name="NEJM"></ref>
*[[Special:MyLanguage/Alcohol|Alcohol]] (acute and chronic consumption) - 30% of cases in the US <ref>[https://www.uptodate.com/contents/etiology-of-acute-pancreatitis?search=pancreatitis%20etiology&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Vege SS. Etiology of acute pancreatitis. Uptodate.com]</ref>
*[[Special:MyLanguage/Hypertriglyceridemia|Hypertriglyceridemia]]
*ERCP
**Most common post-ERCP complication, usually from mechanical injury from instrumentation of the pancreatic duct or hydrostatic injury from contrast injection
*Drugs ([[Special:MyLanguage/Azathioprine|Azathioprine]], cisplatin, [[Special:MyLanguage/furosemide|furosemide]], [[Special:MyLanguage/tetracycline|tetracycline]], thiazides, sulfa, [[Special:MyLanguage/valproate|valproate]], didanosine, pentamidine, etc)
*Autoimmune disease ([[Special:MyLanguage/Systemic Lupus Erythematosus|SLE]], [[Special:MyLanguage/Sjögren|Sjögren]], etc)
*[[Special:MyLanguage/Abdominal trauma|Abdominal trauma]]
*Postoperative complications
*Infection
**Bacterial: [[Special:MyLanguage/Legionella|Legionella]], [[Special:MyLanguage/Leptospirosis|Leptospirosis]], [[Special:MyLanguage/Mycoplasma pneumoniae|Mycoplasma]], [[Special:MyLanguage/Salmonella|Salmonella]]
**Viral: [[Special:MyLanguage/Mumps|Mumps]], [[Special:MyLanguage/coxsackie|coxsackie]], [[Special:MyLanguage/CMV|CMV]], echo, [[Special:MyLanguage/Viral hepatitis|Hep B]]
**Parasitic: [[Special:MyLanguage/ascaris|ascaris]], [[Special:MyLanguage/cryptosporidium|cryptosporidium]], [[Special:MyLanguage/toxoplasma|toxoplasma]]
*[[Special:MyLanguage/Hypercalcemia|Hypercalcemia]]
*[[Special:MyLanguage/Hyperparathyroidism|Hyperparathyroidism]]
*Ischemia
*[[Special:MyLanguage/PUD|Posterior penetrating ulcer]]
*[[Special:MyLanguage/Scorpions|Scorpion venom]] (Caused by the genre ''Tityus'' and ''Leiurus'' which are distributed in Central/South America and North/East Africa, respectively
*[[Special:MyLanguage/Organophosphate Toxicity|Organophosphate insecticide]]
*Pancreatic or ampullary tumor
*Pancreas divisum with ductular narrowing on pancreatogram
*Oddi sphincter dysfunction
*Idiopathic (15-20% of cases)

==Clinical Features==

*[[Special:MyLanguage/Epigastric pain|Pain]] is the most common symptom and is often characterized by:<ref name="NEJM"></ref>
**Persistent
**Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
**Radiates to back
**The onset may be less abrupt and the pain poorly localized
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]] noted in most
*Abdominal distention is frequent complaint
*[[Special:MyLanguage/Eponyms_(C-E)#Cullen.27s_sign|Cullen sign]] (ecchymosis of periumbilical region) - intrabdominal hemorrhage
*Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
*Pulmonary Findings
**[[Special:MyLanguage/Hypoxemia|Hypoxemia]], [[Special:MyLanguage/ARDS|ARDS]], tachypnea
**Indicates severe pancreatitis
***Diaphragmatic inflammation, pancreatico-pleural fistula

==Differential Diagnosis==

{{Abdominal Pain DDX Epigastric}}

{{Abdominal Pain DDX Diffuse}}

==Evaluation==

[[File:PMC4613590 JoU-2013-0017-g001.png|thumb|Ultrasound of acute pancreatitis with non-homogeneous, hypoechoic area in the body/tail projection attesting to extensive necrosis.]]
[[File:PMC4613590 JoU-2013-0017-g003.png|thumb|Complicated acute pancreatitis with large abscess in the projection of the tail.]]
[[File:Pankreatitis exsudativ CT axial.jpg|thumb|Acute exudative pancreatitis on CT scan]]
[[File:CalcifiedPanDucStoneandSomefluid.png|thumb|Pancreattis with calcified pancreatic duct stones with some free intra-abdominal fluid]]

===Work-Up===

*Lipase
**Amylase is both less sensitive and specific (sensitivity: 67-100%; specificity: 85-98%)<ref>Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.</ref>
*CBC
*Chemistry
*[[Special:MyLanguage/LFTs|LFTs]]
*?[[Special:MyLanguage/Lactate|Lactate]]
*?Triglyceride

====[[Ultrasound: Abdomen|Ultrasound]]====

*Edematous, swollen pancreas
*Gallstones
*Pseudocyst / pancreatic abscess

====CT with IV contrast <ref>UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9 </ref>====

*Little utility early on in disease and unlikely to affect the management of patients with acute pancreatitis during the first week of the illness
*Should be reserved for patients with persisting organ failure, severe pain and signs of sepsis

===Diagnosis===

Two of the following:
*Characteristic abdominal pain
*Lipase level >3x upper limit of normal
**Sensitivity 82-100%, specificity 82-100%<ref>Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.</ref>
**Negative lipase does not exclude pancreatitis in chronic/recurrent disease
**Absolute value not associated with prognosis or severity
*Characteristic findings on [[Special:MyLanguage/ultrasound|ultrasound]] or CT

==Management==

''The core treatment involves supportive care to rest the pancreas. This can be achieved mainly through diet control.''

===Medical===

====Diet====

*NPO (clears is probably ok for mild/moderate cases)
*When restarting diet, eat small, low-fat meals and gradually advance over 3 to 6 days as tolerated
*In patients with mild pancreatitis who are tolerating POs and can most likely be discharged. Instructions regarding a light diet and avoidance of alcohol is necessary<ref name="NEJM"></ref>

====[[Special:MyLanguage/IV Fluids|IV Fluids]]====

*[[Special:MyLanguage/Volume resuscitation|Volume resuscitation]] and constant monitoring of fluid status is important due to the risk of profound [[Special:MyLanguage/hypovolemia|hypovolemia]]<ref>Nathens AB, Curtis JR, Beale RJ, et al. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med 2004;32:2524-2536</ref>
**Maintain urine output at 0.5 mL/kg

====[[Special:MyLanguage/Analgesia|Analgesia]] and [[Special:MyLanguage/Antiemetics|Antiemetics]]====

*For example:
**[[Special:MyLanguage/Dilaudid|Dilaudid]] 1mg or [[Special:MyLanguage/morphine|morphine]] 4mg IV PRN
**[[Special:MyLanguage/Zofran|Zofran]] 4mg IV PRN

====Electrolyte and Other Molecular Management====

*Monitor for [[Special:MyLanguage/hypocalcemia|hypocalcemia]] and treat if symptomatic
*Monitor for development of [[Special:MyLanguage/hypoglycemia|hypoglycemia]] or [[Special:MyLanguage/hyperglycemia|hyperglycemia]]
*Consider albumin replacement if level <2g/dL
*See [[Special:MyLanguage/hypertriglyceridemia|hypertriglyceridemia]] for management of high triglycerides

====[[Special:MyLanguage/Antibiotics|Antibiotics]]====

''Antibiotic use is often controversial and generally only required if there are obvious signs or sources of infection. Prophylactic use is not necessary<ref>Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev.2003; Issue 4, CD002941.</ref> <ref>Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.</ref><ref>Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31</ref><ref>Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27</ref><ref>Manes G, Rabitti PG, Menchise A, et al. Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem. Pancreas. 2003;27:79–83</ref>''
*Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
*[[Special:MyLanguage/Imipenem-cilastatin|Imipenem-cilastatin]], [[Special:MyLanguage/meropenem|meropenem]], or ([[Special:MyLanguage/fluoroquinolone|fluoroquinolone]] + [[Special:MyLanguage/metronidazole|metronidazole]])

===Procedural/Surgical===

====Bowel Decompression====

*Consider placement of an [[Special:MyLanguage/NG tube|NG tube]] only if [[Special:MyLanguage/SBO|SBO]] or [[Special:MyLanguage/ileus|ileus]] is present and symptomatic

====ERCP<ref>Tenner, S., Baillie, J., DeWitt, J. and Vege, S. (2013). American College of Gastroenterology Guideline: Management of Acute Pancreatitis. The American Journal of Gastroenterology, 108(9), pp.1400-1415.</ref>====

*Indicated for patients with gallstone pancreatitis with retained CBD stone or cholangitis (recommended within 24 hours)
*Alternative option for patients with gallstone pancreatitis who are poor operative candidates for cholecystectomy

====Cholecystectomy====

*Indicated for patients with biliary pancreatitis. Patients will generally will benefit from early cholecystectomy, as soon as the patient has recovered, preferably within the same hospital admission.<ref>Kimura Y, Takada T, Kawarada Y et al. JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779396/ J Hepatobiliary Pancreat Surg. 2006;13(1):56-60.]</ref>

====Fluid Collection Drainage====

*Symptomatic walled-off pancreatic fluid collections should be evaluated for a drainage procedure.

==Disposition==

===Discharge===

*Mild case + no biliary disease + no systemic complication + tolerating clears
*Patients can be discharged when oral analgesics control their pain

===Admit===

*All other patients

==Complications==

===Local===

*Pancreatic necrosis
*Pancreatic pseudocyst / abscess
*Portal vein thrombosis
*[[Special:MyLanguage/Abdominal compartment syndrome|Abdominal compartment syndrome]]
*Abdominal pseudoaneurysm
*Intra Abdominal hemorrhage

===Systemic===

*Cardiac dysfunction
*[[Special:MyLanguage/Renal failure|Renal failure]]
*[[Special:MyLanguage/Respiratory failure|Respiratory failure]]
*[[Special:MyLanguage/Shock|Shock]]
*[[Special:MyLanguage/Hypocalcemia|Hypocalcemia]] (due to sequestration in necrotic fat)
*[[Special:MyLanguage/Hyperglycemia|Hyperglycemia]]
*[[Special:MyLanguage/Pleural effusion|Pleural effusion]] with high amylase

==Prognosis==

===APACHE-II===

*Highest sensitivity and specificity in distinguishing mild from severe pancreatitis<ref>Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.</ref>
*Can be used to estimate the risk of ICU mortality based on worse set of labs during a patient's first 24hrs

===CT Severity Index===

A extension of the Balthazar score with stratification of severity based on score.<ref>Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6</ref><ref>Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13[http://pubs.rsna.org/doi/pdf/10.1148/radiol.2233010680 PDF]</ref>
*;Balthazar grading of pancreatitis
:'''A''' = normal pancreas - 0
:'''B''' = enlargement of pancreas - 1
:'''C''' = inflammatory changes in pancreas and peripancreatic fat - 2
:'''D''' = ill defined single fluid collection - 3
:'''E''' = two or more poorly defined fluid collections - 4

*;Pancreatic necrosis
:none - 0
:less than/equal to 30% - 2
:> 30-50 % - 4
:> 50% - 6

*;The maximum score that can be obtained is 10.
:0-3: mild
:4-6: moderate
:7-10: severe

===Ranson criteria===

*Consist of 11 parameters. Five of the factors are assessed at admission, and six of the factors are assessed during the next 48 hours. <ref>Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. PubMed PMID: 4834279</ref>
*Score of 3 or more indicates severe acute pancreatitis.
;On admission:
#Age > 55
#WBC > 16,000
#Blood glucose >200mg/dL
#Lactate dehydrogenase >350 U/L
#Aspartate aminotransferase (AST) >250 U/L
;48 hours:
#Hematocrit fall by > 10%
#BUN increase by >5mg/dL
#Serum Calcium <8mg/dL
#pO2 < 60mmHg
#Base deficit >4 MEq/L
#Fluid Sequestation > 6L

===BISAP===

*Bedside Index for Severity in Acute Pancreatitis<ref>Wu BU et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703.</ref>
*Decreased sensitivity, but outperforms in specificity as compared to Ranson and APACHE II<ref>Gao W et al. The Value of BISAP Score for Predicting Mortality and Severity in Acute Pancreatitis: A Systematic Review and Meta-Analysis. PLoS One. 2015; 10(6): e0130412.</ref><ref>Papachristou GI et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41; quiz 442.</ref>
*Clinically more manageable to obtain, especially in the ED setting
**BUN > 25 mg/dL
**Impaired mental status, defined as disorientation, lethargy, somnolence
**≥2 SIRS Criteria
**Age > 60 years
**Pleural effusion
*Interpretation
**Score of 0-2 had mortality < 2%
**Score of 3-4 has mortality > 15%
**Score of 5 has 22% mortality

==See Also==

*[[Special:MyLanguage/Pancreatitis Guidelines|Pancreatitis Guidelines]]
*[[Special:MyLanguage/Chronic pancreatitis|Chronic pancreatitis]]

==External Links==

*[http://www.mdcalc.com/ransons-criteria-for-pancreatitis-mortality/ MDCalc - Ranson's Criteria]
*[https://www.mdcalc.com/apache-ii-score/ MDCalc - Apache II Score]
*[http://www.mdcalc.com/bisap-score-for-pancreatitis-mortality/ MDCalc - BISAP Score for Pancreatitis Mortality]

==References==

<references/>

[[Category:GI]]

Acute pancreatitis/en - Revision history

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