Acute Pancreatitis

1. See Also
   1. Chronic Pancreatitis
2. Causes
   1. See Pancreatitis Causes
   2. See Medication Causes of Pancreatitis
3. Symptoms
   1. Mid-Epigastric Pain
      1. Steady and boring pain
      2. Radiation to back
      3. Worse with eating
   2. Nausea or Vomiting
4. Signs
   1. General
      1. Low grade fever
   2. Cardiopulmonary Exam
      1. Tachycardia
      2. Hypotension
      3. Hypoxemia (25%)
      4. Left basilar rales (Pleural Effusion)
   3. Abdominal Exam
      1. Abdominal tenderness and rigidity
      2. Bowel sounds decreased
      3. Palpable upper abdominal mass
      4. Cullen's Sign (periumbilical discoloration)
      5. Turner's Sign (flank discoloration)
   4. Skin Exam
      1. Erythematous skin Nodules (Subcutaneous Fat Necrosis)
5. Labs
   1. General
      1. Obtain amylase and Lipase simultaneously on initial evaluation
      2. Expect both increased in Pancreatitis (question diagnosis if only 1 increased)
   2. Serum Amylase elevated
      1. Nonspecific
      2. Returns to normal in 48-72 hours
      3. Normal amylase does not exclude Pancreatitis
      4. Level of elevation does not predict disease severity
   3. Serum Lipase elevated
      1. Specific for pancreatic disease
      2. Returns to normal in 7-14 days
   4. Serum Electrolytes
      1. Hypocalcemia (25%)
      2. Hyperglycemia
   5. Complete Blood Count (CBC)
      1. White Blood Cells increased to 15k-20k
   6. Lipids Elevated
      1. Hypertriglyceridemia (15%)
   7. Liver Function Tests
      1. Serum Bilirubin elevated
      2. Alkaline Phosphatase elevated
      3. Aspartate Aminotransferase elevated (AST)
      4. Hypoalbuminemia (Poor prognosis)
      5. Lactate Dehydrogenase (LDH) elevated (Poor prognosis)
6. Diagnostics
   1. Electrocardiogram
      1. ST segment abnormality
      2. T Wave abnormality
7. Imaging
   1. Abdominal XRay (non-specific abnormalities in 50%)
      1. Total or partial ileus (Sentinel loop)
      2. Spasm of transverse colon
   2. Right Upper Quadrant Transabdominal Ultrasound
      1. Used to identify Cholelithiasis
         1. Gallstone Test Sensitivity 87-98%
      2. May demonstrate Pancreas enlargement or edema
   3. Endoscopic Ultrasonography
      1. Gallstone Test Sensitivity 100%, Specificity 91%
   4. CT Abdomen with contrast (preferred imaging modality)
      1. Identifies edematous Pancreas
      2. Predicts and evaluates Pancreatitis complications
      3. Pancreatitis Test Sensitivity 78%, Specificity 86%
   5. MRI Abdomen
      1. Pancreatitis Test Sensitivity 83%, Specificity 91%
      2. May be indicated if defining peripancreatic changes
   6. Magnetic Resonance Cholangiopancreatography (MRCP)
      1. Consider in cases where ERCP not possible
      2. Similar efficacy to CT in identifying Pancreatitis
      3. Detects Common Bile Duct Stones in 81-100% of cases
         1. Negative Predictive Value: 98%
         2. Positive Predictive Value: 94%
         3. May miss Gallstones <4mm
   7. ERCP Indications
      1. Evaluate atypical causes of Pancreatitis
         1. Microlithiasis
         2. Sphincter of Oddi Dysfunction
         3. Pancreas divisium
         4. Pancreatic duct strictures
      2. Urgent intervention
         1. Biliary Sepsis
         2. Biliary obstruction and severe Pancreatitis
         3. Ascending Cholangitis
         4. Progressive Jaundice or Hyperbilirubinemia
8. Differential Diagnosis
   1. Bowel perforation (peptic ulcer perforation)
   2. Cholecystitis
   3. Acute Intestinal Obstruction
   4. Mesenteric Ischemia
   5. Renal Colic
   6. Myocardial Ischemia (Angina)
   7. Aortic Dissection
   8. Connective Tissue disorders
   9. Pneumonia
   10. Diabetic Ketoacidosis
9. Management
   1. Gastrointestinal rest
      1. Nothing by mouth
      2. Consider nasojejunal Enteral Nutrition
         1. Preferred over parenteral nutrition
         2. Marik (2004) BMJ 328:1407-10
      3. Parenteral antacid
         1. H2 Blocker (e.g. Ranitidine) or
         2. Proton Pump Inhibitor (e.g. Pantoprazole)
   2. Pain Management
      1. Meperidine
   3. Intravenous hydration
   4. Electrolyte disturbance
      1. Hypocalemia (related to saponification)
         1. Replace Serum Calcium as needed
   5. Antibiotics
      1. Indicated only for concurrent infection
      2. Controversial whether to use in pancreatic necrosis
      3. Antibiotic examples: Cipro, Flagyl
   6. Surgical debridement indications (>2 weeks after onset)
      1. Infected pancreatic necrosis
      2. Pancreatic necrosis with clinical deterioration
10. Course
    1. Restart clear liquids on day 3-6
    2. Most cases subside in 3-7 days (90%)
11. Complications
    1. Early Complications
       1. Shock
       2. Gastrointestinal Bleeding
       3. Common bile duct obstruction
       4. Ileus
       5. Splenic infarction
       6. Splenic rupture
       7. Disseminated Intravascular Coagulation (DIC)
       8. Subcutaneous Fat Necrosis
       9. Adult Respiratory Distress Syndrome (ARDS)
       10. Pleural Effusion
       11. Hematuria
       12. Acute Renal Failure
    2. Late Complications
       1. Pancreatic Phlegmon
       2. Pancreatic Pseudocysts
       3. Pancreatic Abscess
       4. Pancreatic Ascites
       5. Pleural Effusion
12. Prognosis
    1. See Ranson Criteria
13. References
    1. Mitchell (2003) Lancet 361:1447-55
    2. Swaroop (2004) JAMA 291:2865-8
    3. Tenner (2004) Am J Gastroenterol 99:2489-94