View source for Acute pancreatitis

==Background==
*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===
*[[Symptomatic Cholelithiasis|Gallstones]] (including microlithiasis) - 35-40% of cases in most parts of the world <ref name="NEJM"></ref>
*[[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>
*[[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 ([[Systemic Lupus Erythematosus|SLE]], [[Sjögren]], etc)
*[[Abdominal trauma]]
*Postoperative complications
*Infection
**Bacterial: [[Legionella]], [[Leptospirosis]], [[Mycoplasma pneumoniae|Mycoplasma]], [[Salmonella]]
**Viral: [[Mumps]], coxsackie, CMV, echo, [[Viral hepatitis|Hep B]]
**Parasitic: Ascaris, cryptosporidium, toxoplasma
*[[Hypercalcemia]]
*Hyperparathyroidism
*Ischemia
*[[PUD|Posterior penetrating ulcer]]
*[[Scorpions|Scorpion venom]]
*[[Organophosphate Toxicity|Organophosphate insecticide]]
*Pancreatic or ampullary tumor
*Pancreas divisum with ductular narrowing on pancreatogram
*Oddi sphincter dysfunction
*Idiopathic (15-20% of cases)

===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>
;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

==Clinical Features==
*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
*Nausea/vomiting noted in most
*Abdominal distention is frequent complaint
*[[Eponyms_(C-E)#Cullen.27s_sign|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==
{{Abdominal Pain DDX Epigastric}}

{{Abdominal Pain DDX Diffuse}}

==Evaluation==
===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
*LFTs
*?[[Lactate]]
*?Triglyceride

====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 [[ultrasound]] or CT

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

===IV Fluids===
*Volume resuscitation and constant monitoring of fluid status is important due to the risk of profound 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

===Analgesia and [[Antiemetics]]===
*For example:
**[[Dilaudid]] 1mg or [[morphine]] 4mg IV PRN
**Zofran 4mg IV PRN

===Electrolyte Management===
*Monitor for [[Hypocalcemia]] and treat if symptomatic

===Glycemic control===
*Monitor for development of hypo or hyperglycemia

===Albumin===
*Consider replacement if level <2g/dL

===Bowel Decompression===
*Consider placement of an [[NG tube]] only if [[SBO]] or [[ileus]] is present and symptomatic

===[[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
*[[Imipenem-cilastatin]], [[meropenem]], or ([[fluoroquinolone]] + [[metronidazole]])

===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.

===[[Hypertriglyceridemia]]===
*See [[hypertriglyceridemia]] for management of high triglycerides

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

===Admit===
*All other patients

==Complications==
===Local===
*Pancreatic necrosis
*Pancreatic pseudocyst / abscess
*Portal vein thrombosis
*Abdominal compartment syndrome
*Abdominal pseudoaneurysm
*Intraabdominal hemorrhage
===Systemic===
*Cardiac dysfunction
*Renal failure
*Respiratory failure
*Shock 
*Hypocalcemia (due to sequestration in necrotic fat)
*Hyperglycemia
*Pleural effusion with high amylase

==See Also==
*[[Pancreatitis Guidelines]]
*[[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]]