Acute Pancreatitis

Kristijan Bogdanovski

Background

  • Common causes: Gallstones (40%), EtOH (30%)
  • Other causes: post-ERCP, pancreatic cancer/obstruction, blunt abdominal trauma, hypertriglyceridemia (TG >1000), hypercalcemia, drugs (thiazides, protease inhibitors, azathioprine, 6MP), mumps, Coxsackie, vasculitis, pregnancy, genetic (PRSS1, SPINK1, CFTR), autoimmune (IgG4), scorpion venom
  • Several scoring systems (all available on MDCalc)
    • BISAP (Evaluate in first 24hours of presentation)
      • Score 3 -5: mortality > 15 %
    • APACHE II (Evaluate in first 24hours of ICU admission)
      • Score> 8: mortality 11 – 18 %
    • Ranson (Evaluate at admission + 48hrs post admission)
      • Score > 3: mortality > 15% (consider ICU admission)
    • Glasgow-Imrie (modified Ranson criteria, used 48h post admission)
      • Score >2 associated with higher mortality (consider ICU admission)

Presentation

  • Must have 2 out of the following 3 criteria:
    • Pain characteristic of pancreatitis (sharp, epigastric, radiating to back)
    • Enzymes (lipase or amylase) >3x ULN (ULN at VUMC = 78)
      • ***Use lipase, much more specific than amylase 131 GASTROENTEROLOGY o
    • Imaging characteristic of pancreatitis (US, CT, MRI)
      • If pain is characteristic and lipase > 3xULN, no need for CT A/P (imaging only really useful if either of the 2 criteria above are equivocal)
  • Grading Severity:
    • Mild: no organ failure or systemic complications
    • Moderate: transient organ failure (<48 hours)
    • Severe: persistent organ failure (>48 hours)

Evaluation

  • Lipase, CBC, CMP, lipid panel, lactate, direct bilirubin
  • Obtain RUQ U/S for all pts, evaluates for gallstones
  • CT A/P w/ IV contrast if indicated
    • Reserved for patients not improving at 48-72 hour to assess for complications
    • If performed at onset, underestimates severity (necrosis takes 72 hours from onset)

Management

  • Fluids, Fluids, Fluids:
    • Bolus 10 mg/kg (if clinically hypovolemic) + 1.5mL/kg/hr Maintenance Fluids
    • Follow HCT and BUN as markers for successful fluid resuscitation
    • Persistent hemoconcentration at 24 hr is associated with necrotizing pancreatitis
  • Pain Control:
    • Common starting narcotic regimen is oxycodone 10 mg q6h PRN and hydromorphone 0.5 mg q4h for breakthrough
  • Nutrition:
    • Do NOT have to make NPO at presentation, restarting enteral feeding as early as tolerated is recommended; addressing fluid resuscitation and pain control will help improve appetite and PO tolerance
    • Start with clear liquid diet or mechanical soft and advance as tolerated
    • Low fat diet (Fatty acids → CCK → trypsinogen to trypsin)
    • If NPO > 72 hours, attempt PO and if fail, place Dobhoff for enteral nutrition at latest by day 5… outcomes with NG/NJ >>> TPN
  • Antibiotics:
    • Fever, leukocytosis common, not an indication for ABX as the necrosis is (often) sterile
    • Infection of the necrosis should be suspected with failure to improve 7 days after onset
      • CT A/P w/ IV contrast recommended to assess for pancreatic or extrapancreatic necrosis or local complications
      • Most likely organisms enteric (E. Coli, Klebsiella, Pseudomonas, Enterococcus)
      • If clinical signs of infection and abdominal imaging demonstrating gas within necrosis, can empirically start ABX without aspirate or culture
      • Use abx with good pancreatic necrotic penetration: Cefepime/FQ + Flagyl or carbapenem
      • EUS or IR guided drain for aspirate: can be done on immature collections for diagnostic purposes but typically only done if collection is walled-off—at least 4 weeks
    • Endoscopic Intervention (cystogastrostomy) has emerged as first-line therapy for symptomatic pseudocysts or walled-off pancreatic necrosis , with step-up therapy to video assisted retroperitoneal debridement (VARD) or surgery when needed

Additional Information

  • Urgent ERCP for choledocholithiasis on imaging, with cholangitis or obstructive jaundice, otherwise elective ERCP (see page on choledocholithiasis)
  • Complications:
    • ARDS, abdominal compartment syndrome, AKI, DIC
    • < 4 weeks after pancreatitis: Peripancreatic fluid collection, acute necrotic collection
    • > 6 weeks after pancreatitis: pancreatic pseudocyst, walled-off necrosis (WON)
    • Most fluid collections should be followed over time as acute collections can resolve and are unable to be sampled safely with EUS
  • Gallstone pancreatitis:
    • All pts should have cholecystectomy once recovered (recurrence is 25-30%) with EGS
    • Performed during initial admission in cases of mild acute pancreatitis
      • Consider age or co-morbid illness precludes fitness for surgery
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