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Management

Characterize the symptoms: ❑ severe abdominal pain and/or ❑ Breathing difficulty and/or ❑ Nausea & vomiting and/or ❑ Hiccups sometimes

Examine the patient: ❑ Fever and/or ❑ Hypotension and/or ❑ Cullen's sign and/or ❑ Grey-Turner's sign and/or ❑ Tachypnea and/or ❑ Abdominal distension and/or tenderness

Consider alternative diagnosis: ❑ Gallstones ❑ Dissecting aortic aneurysm ❑ Pancreatic pseudocyst

Hemodynamic stability?

Stable

Unstable

Order Labs: (Urgent) ❑ Blood urea nitrogen ❑ CBC ❑ Chest X-ray ❑ Hematocrit ❑ serum amylase ❑ serum lipase ❑ serum triglycerides ❑ serum creatinine Order imaging studies: (Urgent) Trans abdominal USG

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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

Acute Pancreatitis

Systemic inflammatory response syndrome? (Urgent)

Yes

No

Risk stratification (Marshall scoring)(Urgent)

Lower risk

Higher risk

Admit to medical ward

Admit to ICU (Urgent)

Fluids: (Urgent) ❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs ❑ Reassess within 6 hrs after admission and for next 24-48 hrs Analgesics: (Urgent) ❑ Opioids are preferred ❑ Mepridine & Morphine may be used as IV drips/pt. controlled analgesia Nutrition: (Urgent) ❑ Immediate oral feeding as soon as pain, vomiting, nausea subside

Fluids: (Urgent) ❑ Initiate with a fluid bolus ❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs ❑ Reassess within 6 hrs after admission and for next 24-48 hrs Analgesics: (Urgent) ❑ Opioids are preferred ❑ Mepridine & Morphine may be used as IV drips/pt. controlled analgesia Nutrition: (Urgent) ❑ Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside ❑ Consider enteral feeding if above not tolerated

Cholangitis or biliary obstruction

Yes

ERCP within 24 hrs/Cholecystectomy to prevent recurrence

No

Consider MRCP/EUS

Clinical improvement within 48-72 hrs

Yes

Assess for ability to maintain oral feeding at the end of 1 week

N o

CECT/MRI

Recovery

Pancreatic necrosis

Failure to improve clinically after 7-10 days of hospitalization

Yes

Supportive treatment

No

Suspect Infected necrosis

❑ CT guided FNA ❑ Empiric antibiotics, necrosis penetrating: ❑ meropenem 1g IV Q8h ❑ ciprofloxacin 400mg IV Q12h plus metronidazole 500 mg IV Q8h for 14 days

Gram stain & Culture (-)

❑ Supportive treatment ❑ Consider repeat CT FNA every 7 days if no improvement

Gram stain & Culture(+)

Infected Necrosis

Clinically stable

Clinically unstable

❑ Continue antibiotics & observe ❑ If asymptomatic no debridement, else consider surgical consultation

Prompt surgical consultation (Urgent)