Pancreas
Acute Pancreatitis
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Acute Pancreatitis
, Pancreatitis
See Also
Chronic Pancreatitis
Causes
See
Pancreatitis Causes
See
Medication Causes of Pancreatitis
Adult common causes
Alcohol Abuse
(35% of cases)
Cholelithiasis
(40% of cases)
Children common causes
Infection (e.g.
Mumps
,
Viral Hepatitis
, Coxsackievirus,
Ascariasis
,
Mycoplasma
)
Abdominal Trauma
(e.g. handlebar injury)
Symptoms
Abdominal Pain
Mid-
Epigastric Pain
,
Left Upper Quadrant Abdominal Pain
or
Periumbilical Abdominal Pain
Radiation into the chest or mid-back
Worse with eating and drinking (especially fatty foods) and in supine position
Boring pain that starts episodically and advances to become constant
Pancreatitis may be painless in some cases (e.g. toxin-induced)
Associated gastrointestinal symptoms
Nausea
or
Vomiting
Indigestion
Abdominal Bloating
, distention or fullness
Clay-colored stool
Other associated symptoms
Decreased
Urine Output
Hiccup
s
Tactile warmth
Signs
Gene
ral
Low grade fever
Altered Mental Status
(severe cases)
Cardiopulmonary Exam
Tachycardia
Hypotension
Hypoxemia
(25%)
Left basilar rales (
Pleural Effusion
)
Abdominal Exam
Abdominal tenderness and guarding in the upper quadrants
Peritoneal signs may be present (e.g. abdominal rigidity or
Rebound Tenderness
Bowel
sounds decreased
Palpable upper abdominal mass
Cullen's Sign
(periumbilical discoloration with subcutaneous
Ecchymosis
and edema)
Grey Turner's Sign
(flank discoloration with
Ecchymosis
)
Skin Exam
Erythematous skin
Nodule
s (
Subcutaneous Fat Necrosis
)
Jaundice
(severe cases)
Labs
Serum
Lipase
elevated (preferred first-line study)
Serum
Lipase
>540-1000 U/L, depending on specific lab (>3 times normal)
Test Sensitivity
for Pancreatitis: 96% (and LR+ 30)
Test Specificity
for Pancreatitis: 96% (and LR- 0.03)
Other conditions (e.g.
Gastroenteritis
,
Diverticulitis
) result in more mild
Lipase
elevations
Returns to normal in 7-14 days
Serum Amylase
elevated
Replaced by Serum
Lipase
, which has higher
Test Sensitivity
and
Test Specificity
Serum Amylase
>360 U/L, depending on specific lab (>3 times normal)
Test Sensitivity
for Pancreatitis: 95% (and LR+ 21)
Test Specificity
for Pancreatitis: 95% (and LR- 0.05)
Returns to normal in 48-72 hours
Precautions
Normal amylase does not exclude Pancreatitis
Level of elevation does not predict disease severity
Some clinicians obtain
Serum Amylase
and serum
Lipase
simultaneously on initial evaluation
Expect both increased in Pancreatitis (question diagnosis if only 1 increased)
Serum
Lipase
to amylase ratio >4 (and especially >5) strongly suggests
Alcohol
ic Pancreatitis
Serum
Electrolyte
s
Hypocalcemia
(25%)
Hyperglycemia
Hypomagnesemia
(
Alcoholism
)
Hypophosphatemia
(
Alcoholism
)
Complete Blood Count
(CBC)
White Blood Cell
s increased to 15k-20k
Hematocrit
repeated within 2 hours of initial 2 L bolus is a marker of adequate initial fluids if <44%
Fastin
g
Triglyceride
s
Hypertriglyceridemia
(15%)
Very severe
Hypertriglyceridemia
(>1000 mg/dl) is responsible for 2-4% of Pancreatitis cases
Consider acute
Serum Triglyceride
lowering with
Insulin Infusion
, plasmapheresis
Urinary trypsinogen-2 Level
May help predict Pancreatitis severity
Urinary trypsinogen-2 >50 ng/ml
Test Sensitivity
for Pancreatitis: 92% (and LR+ 13.1)
Test Specificity
for Pancreatitis: 93% (and LR- 0.09)
Liver Function Test
s
Gallstone Pancreatitis
Serum Bilirubin
elevated
Alkaline Phosphatase
elevated
Alcohol
ic Pancreatitis
Aspartate Aminotransferase
elevated (AST) increased more than
Alanine Aminotransferase
(ALT)
Prognostic indicators
Hypoalbuminemia
Lactate Dehydrogenase
(LDH) elevated
Venous Blood Gas
(or
Arterial Blood Gas
)
Serum Calcium
level
C-Reactive Protein
Interleukin
-6 (IL-6) and
Interleukin
-8 (IL-8) if available
Urinalysis
Diagnostics
Electrocardiogram
May demonstrate non-specific ST segment abnormality or
T Wave
abnormality
Evaluates differential diagnosis in undifferentiated
Epigastric Pain
(referred
Chest Pain
)
Imaging
First-Line Studies
Right Upper Quadrant Transabdominal
Ultrasound
(preferred imaging in early Pancreatitis to evaluate biliary tract)
First-line study in Acute Pancreatitis evaluation (but limited by body habitus and overlying bowel gas)
May demonstrate
Pancreas
enlargement or edema
Evaluate for
Cholelithiasis
! (gallstone Pancreatitis is most common cause, and requires surgical management)
Gallstone
Test Sensitivity
87-98%
CT Abdomen
with contrast (preferred imaging later in Acute Pancreatitis to evaluate for complications)
Consider in severe
Abdominal Pain
, pancreatic necrosis or when other complications are suspected
Acute Pancreatitis typically shows peripancreatic inflammation and fat stranding (but may be absent early in course)
Identifies pancreatic edema and necrosis as well as extrapancreatitc changes including fluid accumulation
Test Sensitivity
for severe Pancreatitis: 78% (and LR+ 5.57)
Test Specificity
for severe Pancreatitis: 86% (and LR- 0.26)
Predicts and evaluates Pancreatitis complications, length of hospital stay and prognosis
See
CT Severity Index in Pancreatitis
(
Balthazar Computed Tomography Severity Index
)
Imaging
Cholangiography
Magnetic Resonance Cholangiopancreatography
(
MRCP
)
Consider in cases where
ERCP
not possible
Similar efficacy to CT in identifying Pancreatitis
Detects
Common Bile Duct Stone
s in 81-100% of cases
Negative Predictive Value
: 98%
Positive Predictive Value
: 94%
May miss
Gallstone
s <4mm
Endoscopic
Ultrasonography
Gallstone
Test Sensitivity
100%,
Specificity
91%
ERCP
Indications
Evaluate atypical causes of Pancreatitis
Microlithiasis
Sphincter of Oddi Dysfunction
Pancreas
divisium
Pancreatic duct strictures
Urgent intervention
Biliary
Sepsis
Biliary obstruction and severe Pancreatitis
Ascending Cholangitis
Progressive
Jaundice
or
Hyperbilirubinemia
Imaging
Other studies
Abdominal XRay (non-specific abnormalities in 50%)
Total or partial ileus (Sentinel loop)
Spasm of transverse colon
MRI
Abdomen
Indications
IV contrast contraindicated
Unclear diagnosis
Refractory Acute Pancreatitis course after 2-3 days of conservative management
May better defining peripancreatic changes
Pancreatitis
Test Sensitivity
83%,
Specificity
91%
Test Sensitivity
for Pancreatitis: 79%, and for severe Pancreatitis, 83%
Test Specificity
for Pancreatitis: 92%, and for severe Pancreatitis 91%
Diagnosis
Atlanta Criteria (requires 2 of 3 findings)
Symptoms suggestive of Pancreatitis (
Epigastric Abdominal Pain
,
Vomiting
, epigastric tenderness)
Increase >3 fold over normal, the serum
Lipase
(>540-1000 U/L, depending on lab) or the
Serum Amylase
Characteristic imaging findings
Differential Diagnosis
Bowel
perforation (peptic ulcer perforation)
Acute Cholecystitis
or
Ascending Cholangitis
Chronic Pancreatitis
Acute
Intestinal Obstruction
Mesenteric Ischemia
Renal Colic
Myocardial Ischemia
(
Angina
)
Aortic Dissection
Connective Tissue Disorder
s
Pneumonia
Gastric outlet obstruction
Acute Hepatitis
Diabetic Ketoacidosis
Pancreatic Cancer
Tubo-Ovarian Abscess
Evaluation
Severity scoring systems
Ranson Criteria
BISAP
Score
Revised Atlanta Criteria for Acute Pancreatitis Severity
Acute Physiology and Chronic Health Evaluation II
(
APACHE II Score
)
Modified Glasgow Severity Criteria for Pancreatitis
(
Imrie Scoring System for Pancreatitis
,
PANCREAS Score
)
BALI Score
Simple scoring system (4 criteria), but requires
Interleukin
-6 (IL-6) level
CT Severity Index in Pancreatitis
(
Balthazar Computed Tomography Severity Index
)
Superior to
Ranson Criteria
and
APACHE II Score
in its predictive value
Bollen (2012) Am J Gastroenterol 107(4): 612-9 [PubMed]
Management
Emergency Department Approach
Protocol Indications
Suspected Acute Pancreatitis (e.g.
Epigastric Abdominal Pain
,
Vomiting
, abdominal tenderness to palpation)
Initial evaluation confirms Pancreatitis diagnosis and identifies gallstone Pancreatitis (or
Common Bile Duct Stone
)
Serum
Lipase
>3 times upper limit normal (threshold approaches 1000, depending on lab used)
RUQ Ultrasound
(preferred) or
CT Abdomen
(if severe Pancreatitis and delayed diagnosis)
Initial Management
Lactated Ringers
(LR) 2 Liter bolus at 10 ml/kg/h, followed by LR at 250 ml/hour
Most important initial single measure
See fluid
Resuscitation
below regarding indications for additional fluid boluses
Other measures
Antiemetic
s (e.g.
Ondansetron
)
Opioid Analgesic
s (e.g.
Hydromorphone
)
Determine underlying cause
Gallstone Pancreatitis
Surgical consult for
Cholecystectomy
Suspected
Common Bile Duct Stone
(bile duct dilitation, increased
Liver Function Test
s)
Obtain
ERCP
(preferred) or
MRCP
Alcohol
ic Pancreatitis
Alcohol
cessation
Alcohol Withdrawal
protocol
Give
Thiamine
,
Multivitamin
,
Folic Acid
,
Magnesium
Hypertriglyceridemia
(
Serum Triglyceride
s >500)
Evaluate for
Diabetes Mellitus
(e.g.
Hemoglobin A1C
)
Very high
Serum Triglyceride
s (>1000 mg/dl)
Admit to ICU and aggressive
Triglyceride
lowering
Early and aggressive
Serum Triglyceride
lowering is associated with better outcomes
Insulin Infusion
0.25 units/kg/h with dextrose infusion unless hyperglycemic
Plasmapheresis (consult nephrology) if
Insulin Infusion
is not effective or Pancreatitis is refractory
Idiopathic Pancreatitis
See
Medication Causes of Pancreatitis
Consult gastroenterology
Consult pharmacy for medication causes
Review patient history for toxin exposures
Later evaluation and management
Early initiation of oral clear fluids, low-fat full liquids and low residue soft-solids prevents bowel atrophy
Disposition: Indications for discharge and outpatient management
Non-toxic appearance
Normal
Vital Sign
s
Tolerating oral intake
Pain controlled on
Oral Analgesic
s
No serious cause of Acute Pancreatitis (e.g. gallstone Pancreatitis, severe
Hypertriglyceridemia
>1000)
Management
Specific Measures
Gastrointestinal rest
Nothing by mouth for first 24 hours
Parenteral
Antacid
H2 Blocker
(e.g.
Ranitidine
) or
Proton Pump Inhibitor
(e.g.
Pantoprazole
)
Transition back to oral intake
Early oral intake is preferred
Start within 24 hours of admission (or of
Cholecystectomy
or other procedure)
Re-initiate oral clear liquids, then
Advance to low fat full liquids, then
Advance to low fat, low-residue, soft solid diet
Older guidelines recommended delayed oral intake
Previously waited until pain well controlled without
Opioid Analgesic
s (typically day 3-6)
Consider nasojejunal
Enteral Nutrition
if no oral intake within first 48 hours
Preferred over parenteral nutrition
Decreased secondary infections
Surgical interventions
Shorter hospital stays
May not be tolerated in severe ileus or very low oncotic pressure
Marik (2004) BMJ 328:1407-10 [PubMed]
Intravenous hydration
Early aggressive intravenous hydration speeds recovery in even mild Acute Pancreatitis
Buxbaum (2017) Am J Gastroenterol 112(5):797-803 [PubMed]
Initial: 2 L (or 20 ml/kg)
Lactated Ringers
at 5-10 ml/kg/hour
Lactated Ringers
is preferred in Acute Pancreatitis (decreased systemic inflammation)
Consider
Normal Saline
instead if
Hypercalcemia
is present
Wu (2011) Clin Gastroenterol Hepatol 9(8):710-7 [PubMed]
Next: Fluid
Resuscitation
up to 250 ml/hour for up to 48 hours to maintain
Urine Output
>0.5 ml/kg/h
Obtain
Hematocrit
within 2 hours of initial fluid bolus (and consider again at 6 hours)
Hematocrit
<44% suggests adequate initial fluid
Resuscitation
(no need to re-bolus)
Hematocrit
>44% is an indication to rebolus LR 2 Liters over 2 hours
Other markers of hydration status and
Resuscitation
effectiveness
IVC Ultrasound for Volume Status
Blood Urea Nitrogen
Opioid Analgesic
s
Start with parenteral agents
Hydromorphone
(
Dilaudid
) or
Morphine Sulfate
Historically
Meperidine
(
Demerol
) was used (but has fallen out of favor due to associated risks)
Transition to oral
Opioid Analgesic
s when tolerating oral fluids
Oral
Hydromorphone
,
Oxycodone
or
Hydrocodone
Monitoring
Vital Sign
s and
Urine Output
recorded every 1-2 hours initially
Transfer patients to
Intensive Care
for
Hypotension
,
Hypoxemia
or
Oliguria
despite aggressive rehydration
Physical examination every 4 to 8 hours
Observe for
Altered Mental Status
Abdominal exam for marked abdominal firmness (
Abdominal Compartment Syndrome
, third spacing)
Laboratory tests every 6 to 12 hours
Comprehensive metabolic panel
Complete Blood Count
Serum Calcium
Serum Magnesium
Serum Glucose
Blood Urea Nitrogen
Imaging
Consider repeat
CT Abdomen
for clinical worsening or signs of complications
Electrolyte
disturbance
Hypocalemia (related to saponification)
Replace
Serum Calcium
as needed
Antibiotics
Antibiotics are not indicated in acute
Alcohol
ic Pancreatitis without necrosis
Absolutely indicated only for concurrent infection (infected
Pancreatic Pseudocyst
,
Pancreatic Abscess
)
Obtain abscess cultures to guide antibiotic therapy
Controversial whether to use in pancreatic necrosis
Infections occur in one third of necrotizing Pancreatitis cases
AGA as of 2018 recommends NO prophylactic antibiotics regardless of necrosis severity
Prophylactic antibiotics were previously recommended for necrosis of >30% of
Pancreas
Crockett (2018) gastroenterology 154:1096-1101 +PMID:29409760 [PubMed]
Antibiotic regimens (if indicated) for infected
Pancreatic Pseudocyst
or
Pancreatic Abscess
Piperacillin
-Tazobactam 3.375 g IV every 6 hours
Imipenem/Cilastin (Primaxin) 0.5 to 1 g IV every 6 hours
Villatoro (2010) Cochrane Database Syst Rev (5): CD002941 [PubMed]
Meropenem 1 g IV every 8 hours
Moxifloxacin
400 mg IV every 24 hours
(2018) Sanford Guide
Do not use
Probiotic
s (contraindicated in Acute Pancreatitis)
Besselink (2008) Lancet 371(9613): 651-9 [PubMed]
Surgical debridement indications
Gallstone Pancreatitis
Cholecystectomy
is contraindicated in necrotizing Pancreatitis until inflammation improves
Early
Cholecystectomy
shortens hospital stay without increased surgical complications
Aboulian (2010) Ann Surg 251(4): 615-9 [PubMed]
Consider
ERCP
with sphincterotomy
Indicated in severe gallstone Pancreatitis (especially if
Acute Cholangitis
is present or unresolved obstruction)
Sharma (1999) Am J Gastroenterol 94(11): 3211-14 [PubMed]
Ayub (2004) Cochrane Database Syst Rev (4): CD003630 [PubMed]
Non-
Gallstone
related
Surgical indications
Infected pancreatic necrosis
Pancreatic necrosis with clinical deterioration
Severe Pancreatitis and persistent fluid collections (e.g. >2 weeks after onset)
Approach
Minimally invasive techniques are preferred (e.g. percutaneous CT guided aspiration)
Course
Restart clear liquids on day 3-6
Most cases subside in 3-7 days (90%)
Complications
Early Complications
Shock
Gastrointestinal Bleeding
(including from gastric
Varices
)
Common bile duct obstruction
Ileus
Bowel
infarction
Abdominal Compartment Syndrome
Mesenteric Venous Thrombosis
Splenic venous thrombosis (Splenic infarction)
Pancreatic arterial pseudoaneurysm
Splenic Rupture
Disseminated Intravascular Coagulation
(DIC)
Subcutaneous Fat Necrosis
Adult Respiratory Distress Syndrome
(
ARDS
)
Pleural Effusion
Hematuria
Acute Renal Failure
Late Complications
Pancreatic Phlegmon
Pancreatic Pseudocyst
Pancreatic necrosis
Pancreatic Abscess
Pancreatic
Ascites
Pleural Effusion
Chronic Pancreatitis
Prognosis
See
Ranson Criteria
See
BALI Score
See
BISAP
Score
See
Revised Atlanta Criteria for Acute Pancreatitis Severity
See
CT Severity Index in Pancreatitis
(
Balthazar Computed Tomography Severity Index
)
See
Acute Physiology and Chronic Health Evaluation II
(
APACHE II Score
)
See
Modified Glasgow Severity Criteria for Pancreatitis
(
Imrie Scoring System for Pancreatitis
,
PANCREAS Score
)
Findings that most increase mortality risk
Hemorrhagic Pancreatitis
Multiorgan dysfunction or failure
Necrotizing Pancreatitis (especially with concurrent infection or abscess)
Dervenis (1999) Int J Pancreatol 25(3): 195-210 [PubMed]
References
Mitchell (2003) Lancet 361:1447-55 [PubMed]
Swaroop (2004) JAMA 291:2865-8 [PubMed]
Tenner (2004) Am J Gastroenterol 99:2489-94 [PubMed]
Quinlan (2014) Am Fam Physician 90(9): 632-9 [PubMed]
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