Acute pancreatitis: Difference between revisions
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==Clinical Features==
==Clinical Features==
*Pain
Pain is the most common symptom and is often characterized by:<ref name="NEJM"></ref>
**Persistent
**Persistent
**Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
**Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
**Radiates to back
**Radiates to back
**The onset may be less abrupt and the pain poorly localized
*Nausea/vomiting noted in most
*Nausea/vomiting noted in most
*Abdominal distention is frequent complaint
*Abdominal distention is frequent complaint

Revision as of 22:17, 23 November 2016

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

Prognosis

APACHE-II

  • Highest sensitivity and specificity in distinguishing mild from severe pancreatitis[2]
  • 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.[3][4]

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. [5]

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 >5mg/dL
  3. Serum Calcium <8mg/dL
  4. pO2 < 60mmHg
  5. Base deficit >4 MEq/L
  6. Fluid Sequestation > 6L

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
    • Hypoxemia, ARDS, tachypnea
    • Indicates severe pancreatitis
      • Diaphragmatic inflammation, pancreatico-pleural fistula

Differential Diagnosis

Epigastric Pain

Diffuse Abdominal pain

Evaluation

Two of the following:

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

Work-Up

  • Lipase >3x normal limit (sensitivity 100%, specificity 99%[6])
  • CBC
  • Chemistry
  • LFT
  • ?Lactate
  • ?Triglyceride

Imaging

Ultrasound

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

CT with IV contrast [7]

  • 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 patients with severe biliary pancreatitis with retained CBD stone or cholangitis

Management

Place the pancreas at rest

  • 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.
  • IVF
    • Maintain urine output at 0.5 mL/kg
  • Analgesia
  • Antiemetics
  • Hypocalcemia
    • Treat if symptomatic
  • Glycemic control
  • Albumin
    • Consider if level <2
  • NGT if ileus is present
  • Antibiotics[8] [9][10][11][12]
  • ERCP
  • Cholecystectomy
    • Patients with biliary pancreatitis generally will benefit from early cholecystectomy, as soon as the patient has recovered, preferably within the same hospital admission.[13]
  • Drainage
    • Symptomatic walled-off pancreatic fluid collections should be evaluated for a drainage procedure.
  • See hypertriglyceridemia for management of high TGs

Disposition

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

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. ↑ 1.0 1.1 1.2 Whitcomb D. Acute Pancreatitis. N Engl J Med 2006; 354:2142-215
  2. ↑ Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
  3. ↑ Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6
  4. ↑ Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13PDF
  5. ↑ 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
  6. ↑ Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
  7. ↑ UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9
  8. ↑ 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.
  9. ↑ Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.
  10. ↑ Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31
  11. ↑ Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27
  12. ↑ 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
  13. ↑ 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.
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