EMed

Acute Pancreatitis

Based on the RCSI Clinical Guidelines for management of pancreatitis

Epidemiology

  • Incidence rising
  • 32/100,000 population
  • Relapse common
  • M > F (alcohol)
  • Gallstone disease then alcohol are the main causes
  • Mortality should be <10% overall (<30% in severe)

Making the diagnosis

  • Appropriate clinical setting with x4 rise in amylase
  • Serum lipase may help (remains elevated longer)
  • Trypsinogen, elastase-1 & phospholipase no better than amylase
  • Request erect CXR in all
  • Request USS liver (lithiasis ± ductal dilatation)
  • LFTs (early abnormal LFTs suggest gall stone aetiology)
  • CT if above inconclusive
  • ± laparoscopy/laparotomy to exclude other pathology
  • After acute phase, check Ca++ and fasting lipid profile
  • ERCP is not warranted for self limiting acute pancreatitis
  • Consider MRCP & EUS if jaundiced and initial Ix reveal no evidence of gallstones

Causes (I get smashed)

I Idiopathic
G Gallstones
E Ethanol
T Trauma
S Steroids
M Mumps/Malignancy
A Autoimmune
S Scorpion/spider venom
H Hyperlipidaemia/↑Ca++
E ERCP
D Drugs

Severity stratification

Ranson's Criteria

At presentation

  1. Age > 55 years
  2. WCC > 16,000/mm
  3. Glu > 10mmol/L
  4. LDH > 350IU/L
  5. AST > 250 IU/L

Developing first 48 hrs

  1. Haematocrit ↓>10%
  2. Urea >16mmol/L
  3. Ca++ <2mmol/L
  4. Pa02 <8 kPa
  5. Base deficit >4 mmol/L
  6. Fluid sequestration > 6L

Glasgow criteria

  1. WCC >15,000 mm3
  2. Blood glucose >10 mmol/L
  3. Blood urea >16 mmol/L
  4. LDH >600IU/L
  5. AST>200IU/L
  6. Plasma albumin <32g/L
  7. Uncorrected plasma Ca++ <2mmol/L
  8. Arterial Pa02 <8 kPa

Glasgow scoring system most reflects our the patient population.

APACHE II scoring in acute pancreatitis

  1. Temperature
  2. Mean arterial pressure
  3. Heart rate (ventricular response)
  4. Respiratory rate (ventilated or non-ventilated)
  5. Oxygenation
  6. Arterial pH
  7. Serum sodium
  8. Serum potassium
  9. Serum creatinine (Double score if ARF*)
  10. Haematocrit
  11. WCC
  12. Glasgow coma score (score = 15 – actual GCS)

The APACHE II score is given by the sum of the acute physiology score and points given for age and chronic health evaluation.

Notes

  • Serum CRP = best single poor prognostic indicator
  • Age and obesity are also poor prognosis
  • Those with poor prognosis (> 3 on Glasgow / Ranson's) who do not improve (or deteriorate) within 72hrs should have a dynamic contract enhances CT:
    • CT confirms Dx
    • Assesses severity
    • Documents complication

Initial Management

Mild pancreatitis

  • IV fluids  (NGT only if persistent vomiting)
  • Urinary catheter, antibiotics & CT scan are not usually necessary
  • The majority of patients with acute pancreatitis fall into this category and will have an uneventful self-limiting illness

Predicted severe pancreatitis

  • Call for help - these patients require multidisciplinary care in a HDU setting
  • Monitor vitals at least hourly
  • Early IV fluids and US guided CVP monitoring
  • Insert urinary catheter (± NGT if vomiting)
  • Assess blood gases regularly (± ITU review if cardiopulmonary compromise)
  • Early dynamic CT to ID pancreatic necrosis, (accuracy 82%-90%), fluid collections or abscess

Ongoing care

  • Urgent ERCP and sphincterotomy may be necessary in cases of gallstone pancreatitis which do not settle
  • Complications and mortality are decreased with early ERCP and sphincterotomy in patients with ductal calculi
  • Antibiotics - please consult with local microbiologist early as conflicting evidence exists
  • Check with micro. before starting antibiotics
  • Surgical debridement should be considered in those with appropriate clinical signs of sepsis with proven infected necrosis
  • Fine needle aspiration for bacteriology (FNAB) of pancreatic or peripancreatic necrosis appears to be safe and reliable
  • Nutritional support - nasojejunal tube enteral feeding may be superior
  • Regular FBC, clotting and biochemical makers for sepsis, DIC and inflammatory. Regular CXR, CT / USS for complications
  • Timing of surgery is controversial ( more details in RCSI Guidelines 2005 [Local copy])

Content by Dr Íomhar O' Sullivan. Based on the RCSI Guidelines 2005. Last review 24/10/22.