Acute pancreatitis

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[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
  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

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

Differential Diagnosis

Epigastric Pain

Diffuse Abdominal pain

Evaluation

Work-Up

  • Lipase
    • Amylase is 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 and Other Molecular Management

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[14] [15][16][17][18]

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.

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. 1.0 1.1 1.2 1.3 Whitcomb D. Acute Pancreatitis. N Engl J Med 2006; 354:2142-215
  2. Vege SS. Etiology of acute pancreatitis. Uptodate.com
  3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
  4. Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6
  5. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13PDF
  6. 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
  7. Wu BU et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703.
  8. 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.
  9. 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.
  10. Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
  11. UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9
  12. Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
  13. 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
  14. 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.
  15. Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.
  16. Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31
  17. Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27
  18. 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
  19. 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.
  20. 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.

Authors:

Ross Donaldson