Acute pancreatitis: Difference between revisions
| Line 105: | Line 105: | ||
==Evaluation== | ==Evaluation== | ||
===Work-Up=== | ===Work-Up=== | ||
*Lipase | *Lipase | ||
**Not necessary to send amylase, as 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 | *CBC | ||
*Chemistry | *Chemistry | ||
* | *LFTs | ||
*?[[Lactate]] | *?[[Lactate]] | ||
*?Triglyceride | *?Triglyceride | ||
| Line 125: | Line 125: | ||
Two of the following: | Two of the following: | ||
*Characteristic abdominal pain | *Characteristic abdominal pain | ||
*Lipase level 3x upper limit of normal | *Lipase level >3x upper limit of normal | ||
*Negative lipase does not exclude pancreatitis in chronic/recurrent disease | **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 | **Absolute value not associated with prognosis or severity | ||
*Characteristic findings on [[ultrasound]] or CT | *Characteristic findings on [[ultrasound]] or CT | ||
Revision as of 17:49, 7 June 2018
Background
- Acute inflammatory process that may involve surrounding tissue and remote organ systems[1]
- Disease can range from mild inflammation to severe necrosis and multi-organ failure
Etiology
- Gallstones (including microlithiasis) - 35-40% of cases in most parts of the world [1]
- Alcohol (acute and chronic consumption) - 30% of cases in the US [2]
- 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
- Bacterial: Legionella, Leptospirosis, Mycoplasma, Salmonella
- Viral: Mumps, coxsackie, CMV, echo, Hep B
- Parasitic: Ascaris, cryptosporidium, toxoplasma
- 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)
Prognosis
APACHE-II
- Highest sensitivity and specificity in distinguishing mild from severe pancreatitis[3]
- 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.[4][5]
- 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. [6]
- 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[7]
- Decreased sensitivity, but outperforms in specificity as compared to Ranson and APACHE II[8][9]
- 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:[1]
- 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
- Cullen sign (ecchymosis of periumbilical region) - intrabdominal hemorrhage
- Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
- Pulmonary Findings
Differential Diagnosis
Epigastric Pain
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease with or without perforation
- Gastritis
- Pancreatitis
- Gallbladder disease
- Myocardial Ischemia
- Splenic Infarctionenlargement/rupture/aneurysm
- Pericarditis/Myocarditis
- Aortic dissection
- Hepatitis
- Pyelonephritis
- Pneumonia
- Pyogenic liver abscess
- Fitz-Hugh-Curtis Syndrome
- Hepatomegaly due to CHF
- Bowel obstruction
- SMA syndrome
- Pulmonary embolism
- Bezoar
- Ingested foreign body
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Evaluation
Work-Up
- Lipase
- Not necessary to send amylase, as both less sensitive and specific (sensitivity: 67-100%; specificity: 85-98%)[10]
- CBC
- Chemistry
- LFTs
- ?Lactate
- ?Triglyceride
Ultrasound
- Edematous, swollen pancreas
- Gallstones
- Pseudocyst / pancreatic abscess
CT with IV contrast [11]
- 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%[12]
- 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[1]
IV Fluids
- Volume resuscitation and constant monitoring of fluid status is important due to the risk of profound hypovolemia[13]
- Maintain urine output at 0.5 mL/kg
Analgesia and Antiemetics
Electrolyte managment
- Monitor for Hypocalcemia
- Treat if symptomatic
Glycemic control
- Monitor for development of hypo or hyperglycemia
Albumin
- Consider replacement if level <2g/dL
Bowel Decompression
Antibiotics
Antibiotic use is often controversial and generally only required if there are obvious signs or sources of infection. Prophylactic use is not necessary[14] [15][16][17][18]
- Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
- Imipenem-cilastatin, meropenem, or (fluoroquinolone + metronidazole)
ERCP[19]
- 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.[20]
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
External Links
References
- ↑ 1.0 1.1 1.2 1.3 Whitcomb D. Acute Pancreatitis. N Engl J Med 2006; 354:2142-215
- ↑ Vege SS. Etiology of acute pancreatitis. Uptodate.com
- ↑ Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
- ↑ Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6
- ↑ Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13PDF
- ↑ 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
- ↑ Wu BU et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703.
- ↑ 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.
- ↑ 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.
- ↑ Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
- ↑ UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9
- ↑ Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
- ↑ 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
- ↑ 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.
- ↑ Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.
- ↑ Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31
- ↑ Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27
- ↑ 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
- ↑ 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.
- ↑ Kimura Y, Takada T, Kawarada Y et al. JPN Guidelines for the management of acute pancreatitis: treatment of gallstone-induced acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006;13(1):56-60.