Acute pancreatitis approach: Difference between revisions
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==Overview== | ==Overview== | ||
The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition. Cross-sectional imaging modalities may shed light to the local complications associated with acute pancreatitis and minimally invasive surgery may be performed to manage some complications (e.g. pancreatic necrosis). | The mainstay of treatment in acute pancreatitis involves pain control, bowel rest ([[NPO]] or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition. Cross-sectional imaging modalities may shed light to the local complications associated with acute pancreatitis and minimally invasive surgery may be performed to manage some complications (e.g. pancreatic [[necrosis]]). | ||
==Approach to Therapy== | ==Approach to Therapy== | ||
According to the American college of gastroenterology, following are the guidelines for | According to the American college of gastroenterology, following are the guidelines for initial assessment and risk stratification for acute pancreatitis:<ref name="pmid23896955">{{cite journal| author=Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology| title=American College of Gastroenterology guideline: management of acute pancreatitis. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 9 | pages= 1400-15; 1416 | pmid=23896955 | doi=10.1038/ajg.2013.218 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23896955 }}</ref><ref name="pmid22425589">{{cite journal |vauthors=Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, Singh VK, Slivka A, Whitcomb DC, Yadav D, Banks PA, Papachristou GI |title=Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis |journal=Gastroenterology |volume=142 |issue=7 |pages=1476–82; quiz e15–6 |year=2012 |pmid=22425589 |doi=10.1053/j.gastro.2012.03.005 |url=}}</ref><ref name="pmid10824690">{{cite journal |vauthors=Brown A, Orav J, Banks PA |title=Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis |journal=Pancreas |volume=20 |issue=4 |pages=367–72 |year=2000 |pmid=10824690 |doi= |url=}}</ref><ref name="pmid1595648">{{cite journal |vauthors=Tran DD, Cuesta MA |title=Evaluation of severity in patients with acute pancreatitis |journal=Am. J. Gastroenterol. |volume=87 |issue=5 |pages=604–8 |year=1992 |pmid=1595648 |doi= |url=}}</ref><ref name="pmid16671062">{{cite journal |vauthors=Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW |title=Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis |journal=Br J Surg |volume=93 |issue=6 |pages=738–44 |year=2006 |pmid=16671062 |doi=10.1002/bjs.5290 |url=}}</ref><ref name="pmid11872053">{{cite journal |vauthors=Buter A, Imrie CW, Carter CR, Evans S, McKay CJ |title=Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis |journal=Br J Surg |volume=89 |issue=3 |pages=298–302 |year=2002 |pmid=11872053 |doi=10.1046/j.0007-1323.2001.02025.x |url=}}</ref><ref name="pmid20523325">{{cite journal |vauthors=Papachristou GI, Muddana V, Yadav D, Whitcomb DC |title=Increased serum creatinine is associated with pancreatic necrosis in acute pancreatitis |journal=Am. J. Gastroenterol. |volume=105 |issue=6 |pages=1451–2 |year=2010 |pmid=20523325 |doi=10.1038/ajg.2010.92 |url=}}</ref><ref name="pmid9336784">{{cite journal |vauthors=Heller SJ, Noordhoek E, Tenner SM, Ramagopal V, Abramowitz M, Hughes M, Banks PA |title=Pleural effusion as a predictor of severity in acute pancreatitis |journal=Pancreas |volume=15 |issue=3 |pages=222–5 |year=1997 |pmid=9336784 |doi= |url=}}</ref><ref name="pmid8495317">{{cite journal |vauthors=Funnell IC, Bornman PC, Weakley SP, Terblanche J, Marks IN |title=Obesity: an important prognostic factor in acute pancreatitis |journal=Br J Surg |volume=80 |issue=4 |pages=484–6 |year=1993 |pmid=8495317 |doi= |url=}}</ref><ref name="pmid8044613">{{cite journal |vauthors=Mann DV, Hershman MJ, Hittinger R, Glazer G |title=Multicentre audit of death from acute pancreatitis |journal=Br J Surg |volume=81 |issue=6 |pages=890–3 |year=1994 |pmid=8044613 |doi= |url=}}</ref><ref name="pmid11128978">{{cite journal |vauthors=Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA |title=Does mortality occur early or late in acute pancreatitis? |journal=Int. J. Pancreatol. |volume=28 |issue=2 |pages=91–5 |year=2000 |pmid=11128978 |doi=10.1385/IJGC:28:2:091 |url=}}</ref><ref name="pmid15306596">{{cite journal |vauthors=Johnson CD, Abu-Hilal M |title=Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis |journal=Gut |volume=53 |issue=9 |pages=1340–4 |year=2004 |pmid=15306596 |pmc=1774183 |doi=10.1136/gut.2004.039883 |url=}}</ref><ref name="pmid18362837">{{cite journal |vauthors=Lytras D, Manes K, Triantopoulou C, Paraskeva C, Delis S, Avgerinos C, Dervenis C |title=Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis? |journal=Pancreas |volume=36 |issue=3 |pages=249–54 |year=2008 |pmid=18362837 |doi=10.1097/MPA.0b013e31815acb2c |url=}}</ref> | ||
{| class="wikitable" style="width:70%;" | {| class="wikitable" style="width:70%;" | ||
!Recommendation | !Recommendation | ||
| Line 28: | Line 28: | ||
{| class="wikitable" | {| class="wikitable" | ||
!Intrinsic patient related risk factors | !Intrinsic patient related risk factors | ||
! | ! | ||
|- | |- | ||
|''Patient characteristics'' | | rowspan="4" |''Patient characteristics'' | ||
|Age >55 years | |Age >55 years | ||
|- | |- | ||
|Obesity (BMI>30kg/m<sup>2</sup>) | |||
|Obesity (BMI>30kg/m) | |||
|- | |- | ||
|Altered mental status | |Altered mental status | ||
|- | |- | ||
|Comorbid disease | |Comorbid disease | ||
|- | |- | ||
|''The systemic inflammatory response syndrome (SIRS)'' | | rowspan="4" |''The systemic inflammatory response syndrome (SIRS)'' | ||
Presence of >2 of the following criteria | Presence of >2 of the following criteria | ||
| | |Pulse >90 beats/min | ||
| | |- | ||
| | |Respirations >20/min | ||
or PaCO<sub>2</sub> >32mmHg | |||
|- | |||
|Temperature >38°C or <36°C | |||
|- | |||
|WBC count >12,000 or <4000 cells/mm<sup>3</sup> | |||
or >10% immature neutrophils (bands) | |||
|- | |||
| rowspan="5" |''Laboratory findings'' | |||
|BUN >20 mg/dl | |||
|- | |- | ||
| | |Rising BUN | ||
|- | |- | ||
| | |HCT >44% | ||
|- | |- | ||
| | |Rising HCT | ||
|- | |- | ||
| | |Elevated creatinine | ||
|- | |- | ||
| | | rowspan="3" |''Radiology findings'' | ||
|Pleural effusions | |||
| | |||
| | |||
|- | |- | ||
| | |Pulmonary infiltrates | ||
|- | |- | ||
| | |Multiple or extensive extrapancreatic collections | ||
|} | |} | ||
Latest revision as of 19:07, 21 December 2017
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Acute pancreatitis Microchapters |
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Acute pancreatitis approach On the Web |
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American Roentgen Ray Society Images of Acute pancreatitis approach |
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Risk calculators and risk factors for Acute pancreatitis approach |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]
Overview
The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition. Cross-sectional imaging modalities may shed light to the local complications associated with acute pancreatitis and minimally invasive surgery may be performed to manage some complications (e.g. pancreatic necrosis).
Approach to Therapy
According to the American college of gastroenterology, following are the guidelines for initial assessment and risk stratification for acute pancreatitis:[1][2][3][4][5][6][7][8][9][10][11][12][13]
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed | Moderate | Strong |
| Risk assessment should be performed to stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting | Moderate | Conditional |
| Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible | Low | Strong |
| Intrinsic patient related risk factors | |
|---|---|
| Patient characteristics | Age >55 years |
| Obesity (BMI>30kg/m2) | |
| Altered mental status | |
| Comorbid disease | |
| The systemic inflammatory response syndrome (SIRS)
Presence of >2 of the following criteria |
Pulse >90 beats/min |
| Respirations >20/min
or PaCO2 >32mmHg | |
| Temperature >38°C or <36°C | |
| WBC count >12,000 or <4000 cells/mm3
or >10% immature neutrophils (bands) | |
| Laboratory findings | BUN >20 mg/dl |
| Rising BUN | |
| HCT >44% | |
| Rising HCT | |
| Elevated creatinine | |
| Radiology findings | Pleural effusions |
| Pulmonary infiltrates | |
| Multiple or extensive extrapancreatic collections |
References
- ↑ Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955.
- ↑ Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, Singh VK, Slivka A, Whitcomb DC, Yadav D, Banks PA, Papachristou GI (2012). "Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis". Gastroenterology. 142 (7): 1476–82, quiz e15–6. doi:10.1053/j.gastro.2012.03.005. PMID 22425589.
- ↑ Brown A, Orav J, Banks PA (2000). "Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis". Pancreas. 20 (4): 367–72. PMID 10824690.
- ↑ Tran DD, Cuesta MA (1992). "Evaluation of severity in patients with acute pancreatitis". Am. J. Gastroenterol. 87 (5): 604–8. PMID 1595648.
- ↑ Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW (2006). "Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis". Br J Surg. 93 (6): 738–44. doi:10.1002/bjs.5290. PMID 16671062.
- ↑ Buter A, Imrie CW, Carter CR, Evans S, McKay CJ (2002). "Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis". Br J Surg. 89 (3): 298–302. doi:10.1046/j.0007-1323.2001.02025.x. PMID 11872053.
- ↑ Papachristou GI, Muddana V, Yadav D, Whitcomb DC (2010). "Increased serum creatinine is associated with pancreatic necrosis in acute pancreatitis". Am. J. Gastroenterol. 105 (6): 1451–2. doi:10.1038/ajg.2010.92. PMID 20523325.
- ↑ Heller SJ, Noordhoek E, Tenner SM, Ramagopal V, Abramowitz M, Hughes M, Banks PA (1997). "Pleural effusion as a predictor of severity in acute pancreatitis". Pancreas. 15 (3): 222–5. PMID 9336784.
- ↑ Funnell IC, Bornman PC, Weakley SP, Terblanche J, Marks IN (1993). "Obesity: an important prognostic factor in acute pancreatitis". Br J Surg. 80 (4): 484–6. PMID 8495317.
- ↑ Mann DV, Hershman MJ, Hittinger R, Glazer G (1994). "Multicentre audit of death from acute pancreatitis". Br J Surg. 81 (6): 890–3. PMID 8044613.
- ↑ Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA (2000). "Does mortality occur early or late in acute pancreatitis?". Int. J. Pancreatol. 28 (2): 91–5. doi:10.1385/IJGC:28:2:091. PMID 11128978.
- ↑ Johnson CD, Abu-Hilal M (2004). "Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis". Gut. 53 (9): 1340–4. doi:10.1136/gut.2004.039883. PMC 1774183. PMID 15306596.
- ↑ Lytras D, Manes K, Triantopoulou C, Paraskeva C, Delis S, Avgerinos C, Dervenis C (2008). "Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis?". Pancreas. 36 (3): 249–54. doi:10.1097/MPA.0b013e31815acb2c. PMID 18362837.