Acute Pancreatitis

Pt >55 y/o with h/o alcoholism, biliary colic presents with sudden onset epigastric abdominal pain radiating to the back. Reports N/V, recent abdominal trauma. Current medications include estrogen HRT, furosemide, valproic acid, azathioprine, sulfonamide/tetracycline abx. Scleral icterus, decreased bowel sound, abdominal tenderness/guarding on exam. Positive Cullen and Grey-Turner sign.

  • Clinical dx of pancreatitis due to abdominal pain + serum amylase and/or lipase* 3x ULN

  • Suspected alcoholic pancreatitis due to Lipase/amylase >4; obtain Mg2+ and phosphorus levels

  • Obtain initial CBC, CMP, LDH, lipid panel, U/A

  • CBC, CMP (BUN, glucose, CA), Mg2+ q12h for 48h s/p admission

  • Perform u/s exam; consider f/u with contrast CT

  • Treatment

    • Initial 20mL/kg LR bolus over 1hr, then 300mL/hr x48hr; maintain UOP > 0.5mL/kg

    • IV morphine 2mg q2h; titrate per sx

    • Initial bowel rest; consider NJ nutrition if prolonged bowel rest required

    • Transition to PO fluid, low fat diet when pain controlled

    • >30% necrosis on CT: Start abx ppx with imipenem/cilastatin

  • Procedures

    • Suspected gallstone; consult GI for ERCP and consider cholecystectomy

    • Infected necrosis/persistent fluid collections on CT; c/s for CT-guided aspiration vs. surgical debridement

    • Monitor for 48-72 hours; evaluation/prognosis per Atlanta, BALI, Ranson, or APACHE II criteria

Notes

  • Imipenem/cilastatin (Primaxin IV) decreases pancreatic necrosis infection, but does not decrease mortality

Chronic Pancreatitis

45 y/o pt with h/o alcoholism, documented genetic disorder, autoimmune disease including IBD, previous radiation therapy to abdomen presents with acute on chronic abdominal pain. New onset midepigastric postprandial pain that radiates to the back; some relief with sitting upright/leaning forward. Reports pale, foul-smelling, bulky, and difficult to flush stools. Weight loss, jaundice on exam.

  • Obtain CBC, CMP, amylase, lipase, lipid panel
    Suspected autoimmune pancreatitis; obtain IgG4 serum antibody, ANA, rheumatoid factor, ESR

  • One time screen for vitamin D deficiency

  • Contrast CT showing pancreatic ductal calcifications; f/u mass lesions/weight loss/jaundice suspicious for malignancy with EUS + FNAB

  • Presence of complicated/symptomatic pseudocyst and biliary/pancreatic duct obstruction; perform ERCP

  • Pancreatic duct >7mm (large duct disease); consider pancreaticojejunostomy

  • Pancreatic head enlargement noted; consider pancreatoduodenectomy (Whipple)

  • Pain control with Tylenol, NSAID, narcotics

  • 40,000u lipase for steatorrhea and malabsorption

  • Start PPI to reduce pancreatic enzyme deactivation by gastric acid

  • .dmrx for control of DM

  • Pt counseled about low fat diet, small meals for pain control

  • Pt encouraged to consider alcohol, tobacco cessation

  • Refer to GI

Note: Serum lipase, amylase are not specific for chronic pancreatitis

Pancreatitis Evaluation

Atlanta Criteria for Acute Pancreatitis

  • Mild

    • No organ failure, no local complications (fluid collection/necrosis), no systemic complications

    • Typically resolves in first week

  • Moderate if one of the following:

    • Transient organ failure (≤ 48 hours)

    • Local complications

    • Exacerbation of co-morbid disease

  • Severe: Persistent organ failure

BALI Criteria

1 point for each; obtain labs within 48h of admission

  • Blood urea nitrogen level ≥ 25 mg per dL (8.9 mmol per L)

  • Age ≥ 65 years

  • Lactate dehydrogenase level ≥ 300 U per L (5.0 μkat per L)

  • Interleukin-6 level ≥ 300 pg per mL

Mortality rates

  • +3 (>25%)

  • +4 (>50%)

Ranson Criteria

At admission (1 point for each):

  • Age >55

  • Blood glucose >200

  • WBC >16,000

  • AST >250

  • LDH >350

Within 48 hours (1 point for each):

  • Serum Ca <8

  • Hematocrit drop >10%

  • PaO2 <60 mmHg

  • BUN increase >5

  • Base deficit > 4

  • Fluid sequestration >6L

Mortality prognosis

  • 0-2 (2%)

  • 3-4 (15%)

  • 5-6 (40%)

  • 7-8 (100%)