Acute pancreatitis: Difference between revisions
Line 57: Line 57:
****Absolute value not associated w/ prognosis or severity
****Absolute value not associated w/ prognosis or severity
**3. Characteristic findings on US or CT
**3. Characteristic findings on US or CT
*Imaging
===Imaging===
**Ultrasound
*;Ultrasound
***Edematous, swollen pancreas
**Edematous, swollen pancreas
***Gallstones
**Gallstones
***Pseudocyst / pancreatic abscess
**Pseudocyst / pancreatic abscess
**CT w/ IV contrast
*;CT w/ IV contrast <ref>UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9 </ref>
***Helpful to exclude alternative diagnoses, assess severity, identify complications
**Little utility early on in disease and unlikely to  affect the management of patients with acute pancreatitis during the first week of the illness
**ERCP
**Should be reserved for patients with persisting organ failure, severe pain and signs of sepsis
***Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis
*;ERCP
**Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis


==Work-Up==
==Work-Up==

Revision as of 03:56, 17 April 2014

Background

  • Acute inflammatory process that may involve surrounding tissue and remote organ systems
  • Disease can range from mild inflammation to severe necrosis and multi-organ failure

Etiology

  1. Gallstone (including microlithiasis) - 35-40% of cases
  2. Alcohol (acute and chronic consumption)
  3. Hypertriglyceridemia
  4. ERCP
  5. Drugs
    1. Azathioprine, cisplatin, furosemide, tetracycline, thiazides, sulfa
  6. Autoimmune disease
    1. SLE, Sjögren
  7. Abdominal trauma
  8. Postoperative complications
  9. Infection
    1. Bacterial: Legionella, Leptospira, Mycoplasma, Salmonella
    2. Viral: mumps,coxsackie, CMV, echo, Hep B
    3. Parasitic: Ascaris, cryptosporidium, toxoplasma
  10. Hypercalcemia
  11. Hyperparathyroidism
  12. Ischemia
  13. Posterior penetrating ulcer
  14. Scorpion venom
  15. Organophosphate insecticide
  16. Pancreatic or ampullary tumor
  17. Pancreas divisum with ductular narrowing on pancreatogram
  18. Oddi sphincter dysfunction
  19. Idiopathic (15-20% of cases)

Differential Diagnosis

Epigastric Abdominal Pain

Epigastric Pain

Diffuse Abdominal Pain

Diffuse Abdominal pain

Clinical Features

  • Pain
    • Persistent
    • Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
    • Radiates to back
  • N/V noted in most
  • Abd distention is frequent complaint
  • Cullen sign (ecchymosis of periumbilical region) - intrabdominal hemorrhage
  • Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
  • Pulmonary Findings
    • Hypoxemia, ARDS, tachypnea
    • Indicates severe pancreatitis
      • Diaphragmatic inflammation, pancreatico-pleural fistula

Diagnosis

  • Two of the following 3 features:
    • 1. Characteristic abdominal pain
    • 2. Lipase level 3x upper limit of normal
      • Negative lipase does not exclude pancreatitis in chronic/recurrent disease
        • Absolute value not associated w/ prognosis or severity
    • 3. Characteristic findings on US or CT

Imaging

  • Ultrasound
    • Edematous, swollen pancreas
    • Gallstones
    • Pseudocyst / pancreatic abscess
    CT w/ IV contrast [1]
    • 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
    ERCP
    • Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis

Work-Up

  1. Lipase
  2. CBC
  3. Chemistry
  4. LFT
  5. ?Lactate
  6. ?Triglyceride

Treatment

"Place the pancreas at rest"

  1. NPO (clears is probably ok for mild/moderate cases)
  2. IVF
    1. Maintain urine output at 0.5 mL/kg
  3. Analgesia
  4. Antiemetics
  5. Hypocalcemia
    1. Treat if symptomatic
  6. Glycemic control
  7. Albumin
    1. Consider if level <2
  8. NGT if ileus is present
  9. Abx[2] [3][4][5][6]
    1. Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
    2. Imipenem-cilastatin, meropenem, or (fluoroquinolone + metronidazole)
  10. ERCP
    1. Indicated for retained CBD stones or cholangitis

Complications

  1. Local
    1. Pancreatic necrosis
    2. Pancreatic pseudocyst / abscess
    3. Portal vein thrombosis
  2. Systemic
    1. Cardiac dysfunction
    2. Renal failure
    3. Respiratory failure
    4. Shock
    5. Hypocalcemia (due to sequestration in necrotic fat)
    6. Hyperglycemia

Prognosis

  1. APACHE-II
    1. Highest sensitivity and specificity in distinguishing mild from severe pancreatitis
    2. Can be used to estimate risk of hospital death at admission
    3. http://www.globalrph.com/apacheii.htm
  2. CT Severity Index
  3. Ranson criteria
    1. Consist of 11 parameters. Five of the factors are assessed at admission, and six of the factors are assessed during the next 48 hours.
    2. On admission:
      1. Age > 55
      2. WBC > 16,000
      3. Blood glucose >200mg/dL
      4. Lactate dehydrogenase >350 U/L
      5. Aspartate aminotransferase (AST) >250 U/L
    3. 48 hours:
      1. Hematocrit fall by > 10%
      2. BUN increase by >5 mg/dL
      3. Serum Calcium <8 mg/dL
      4. pO2 < 60mmHg
      5. Base deficit >4 MEq/L
      6. Fluid Sequestation > 6L

Disposition

  1. Discharge
    1. Mild case + no biliary disease + no systemic complication + tolerating clears
  2. All other patients should be admitted

See Also

Pancreatitis Guidelines

References

Tintinalli

  1. ↑ UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9
  2. ↑ 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.
  3. ↑ Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.
  4. ↑ Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31
  5. ↑ Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27
  6. ↑ 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
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