Acute pancreatitis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]

Definition

Acute pancreatitis is an acute inflammation of the pancreas characterized by severe abdominal pain and elevated pancreatic enzymes.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Acute pancreatitis from any cause may be life-threatening especially if it progresses to necrotizing pancreatitis. However, in last several years it has come down due to advances in diagnosis and treatment strategies.

Common Causes

• Gallstones

• Alcohol

• Smoking
• Pancreatic tumor

• Trauma

• Medication such as 5-Mercaptopurine, azathioprine, 5-DDI

• Hypertriglyceridemia

• Post - ERCP

• Metabolic - Hypercalcemia and hyperphosphatemia

• Infections

• Toxins such as venom of brown recluse spider, certain arachnids etc.

• Pregnancy

• Idiopathic

• Ischaemic necrosis of pancreas from vascular sources such as vasculitis and atherosclerosis

Management

Acute Pancreatitis

H/o severe abdominal pain, breathing difficulty, hypotension, vomiting, fever, cullen's sign, grey turner's sign

Labs - Sr. Amylase, Sr Lipase, Sr Triglycerides, Abdominal USG, CBC, CECT, MRI

Diagnostic criteria: Any 2 out of 3 Abdominal pain consistent with disease serum amylase or lipase values > 3 times normal consistent findings from abdominal imaging

Risk Stratification

Low risk

High risk

General medical ward

ICU

Inititate supportive care Aggressive fluid resusication with 250-500mL Ringers Lactate per Hr during first 12-24 hours.In sever cases give fluid bolus. Mild cases - oral liquid feeds. In moderate to severe cases enteral feeds, nasogastric or nasojejunal feeds are acceptable.

CT scan

Provide adequate analgesia

Pancreatic necrosis

Stones??

Other causes, treat as per cause.

No

Yes

Surical consult. Emergency cholecystectomy or ERCP within 24 Hrs of admission

Assess in 1 week.

SIRS/Organ failure??

Tolerating oral feeds.

Not tolerating oral feed.

If yes, surgical consultation.Think about CT guided percutaneous aspiration & culture.

Recovery.

Add nutritional support. COnsider CT scan.

Lack of improvement/Worsening of clinical status.