Acute pancreatitis: Difference between revisions
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#*Absolute value not associated w/ prognosis or severity
#*Absolute value not associated w/ prognosis or severity
#Characteristic findings on US or CT
#Characteristic findings on US or CT
===Work-Up===
#Lipase
#CBC
#Chemistry
#LFT
#?Lactate
#?Triglyceride


===Imaging===
===Imaging===
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====ERCP====
====ERCP====
*Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis
*Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis
==Work-Up==
#Lipase
#CBC
#Chemistry
#LFT
#?Lactate
#?Triglyceride


==Treatment==
==Treatment==

Revision as of 06:38, 6 May 2015

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

  • Gallstones (including microlithiasis) - 35-40% of cases
  • Alcohol (acute and chronic consumption)
  • Hypertriglyceridemia
  • ERCP
    • Most common post-ERCP complication, usually from mechanical injury from instrumentation of the pancreatic duct or hydrostatic injury from contrast injection
  • Drugs (Azathioprine, cisplatin, furosemide, tetracycline, thiazides, sulfa, valproate, didanosine, pentamidine, etc)
  • Autoimmune disease (SLE, Sjögren, etc)
  • Abdominal trauma
  • Postoperative complications
  • Infection
  • Hypercalcemia
  • Hyperparathyroidism
  • Ischemia
  • Posterior penetrating ulcer
  • Scorpion venom
  • Organophosphate insecticide
  • Pancreatic or ampullary tumor
  • Pancreas divisum with ductular narrowing on pancreatogram
  • Oddi sphincter dysfunction
  • Idiopathic (15-20% of cases)

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

Differential Diagnosis

Epigastric Abdominal Pain

Epigastric Pain

Diffuse Abdominal Pain

Diffuse Abdominal pain

Diagnosis

Two of the following 3 features:

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

Work-Up

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

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

Treatment

Place the pancreas at rest

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

Complications

  • Local
    1. Pancreatic necrosis
    2. Pancreatic pseudocyst / abscess
    3. Portal vein thrombosis
    4. Abdominal compartment syndrome
    5. Abdominal pseudoaneurysm
    6. Intraabdominal hemorrhage
  • Systemic
    1. Cardiac dysfunction
    2. Renal failure
    3. Respiratory failure
    4. Shock
    5. Hypocalcemia (due to sequestration in necrotic fat)
    6. Hyperglycemia
    7. Pleural effusion with high amylase

Prognosis

APACHE-II

  • Highest sensitivity and specificity in distinguishing mild from severe pancreatitis[7]
  • 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.[8][9]

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. [10]

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
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

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

See Also

Pancreatitis Guidelines

External Links

References

  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
  7. ↑ Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
  8. ↑ Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6
  9. ↑ Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13PDF
  10. ↑ 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
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