- 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)
|M||mumps / malignancy|
- Age > 55 years
- WCC > 16,000/mm
- Glu > 10mmol/L
- LDH > 350IU/L
- AST > 250 IU/L
Developing first 48 hrs
- Haematocrit ↓>10%
- Urea >16mmol/L
- Ca++ <2mmol/L
- Pa02 <8 kPa
- Base deficit >4 mmol/L
- Fluid sequestration > 6L
Glasgow criteria used in acute pancreatitis
- WCC >15,000 mm3
- Blood glucose >10 mmol/L
- Blood urea >16 mmol/L
- LDH >600IU/L
- Plasma albumin <32g/L
- Uncorrected plasma Ca++ <2mmol/L
- Arterial Pa02 <8 kPa
Glasgow scoring system most reflects our the patient population
APACHE II scoring in acute pancreatitis
- Mean arterial pressure
- Heart rate (ventricular response)
- Respiratory rate (ventilated or non-ventilated)
- Arterial pH
- Serum sodium
- Serum potassium
- Serum creatinine (Double score if ARF*)
- 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.
- 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.
- 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 central venous access (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.
- 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]).