Division of General Internal Medicine and Geriatrics

Hospital Medicine

Revised 2015

1. Identify clinical presentation and etiologies of acute

pancreatitis

2. Recognize the importance of severity of pancreatitis in determining management and outcomes

3. Understand the indications for imaging and antibiotics in acute pancreatitis

Objectives

Abdominal pain, distention

Nausea/vomiting (90%)

Fever, tachycardia

Dyspnea/Resp failure

diaphragmatic irritation < pleural effusions < ARDS

Jaundice

Grey-Turner’s/Cullen’s 1% - intra-abdominal hemorrhage

shock, coma

Clinical presentation

Gallstones- 40-70% (increased ALT >150 is 50% sensitive and 96% specific) *women

Alcohol – 30% *men Usually will have a h/o heavy (>50g daily) EtOH use x >5 yrs

Idiopathic -15-20%

Hypertriglyceridemia (TG >1000, 1-4%)

Hypercalcemia

Post-ERCP -3% of diagnostic, 25% if SOD studies

Drugs – direct toxic, immunologic, ischemic causes – cocaine, 6-MP, Imuran, DDI, 5-ASA

Genetic mutations (SPINK, CFTR)

Trauma

Infection – Viruses (mumps, hep B, CMV, HIV), Bacteria (mycoplasma, legionella, salmonella), fungi, parasites

Autoimmune (IgG4)

Scorpion bite

SOD dysfunction? Pancreatic divisum?--controversial

Etiologies

Requires 2 of the following 3 features

1. Characteristic abdominal pain Epigastric, band-like radiating to back, assoc n/v

2. Amylase and/or lipase > 3 times the upper normal limit Amylase rises in 6-12 hrs, elevated 3-5 days

Lipase sensitivity 85-100%; more specific than amylase, stays elevated longer than amylase

3. Characteristic CECT (contrast enhanced CT) findings (or MRI/US) Edema, peripancreatic fat stranding, necrosis, calcifications,

pancreatic heterogeneity

Diagnosis

Plain XR - may have “sentinel loop” (localized ileus) or “colon

cutoff sign” in severe disease CXR - pleural effusion suggests increased risk of complications Abd US - Recommended for all pts with AP; useful to assess for

gallstones, visualization of the pancreas is usually limited by overlying bowel

Contrast CT scan –reserved for pts in whom the diagnosis is unclear, who fail to improve clinically within the first 48 – 72h of admission, or to evaluate complications >90% sensitivity and specificity for diagnosis

MRCP – better to eval for choledocholithiasis, panc duct disruptions

Imaging

1. Interstitial edematous

Acute inflammation of pancreatic parenchyma and peripancreatic tissue

2. Necrotizing Acute Pancreatitis

5-10% of patients

Pancreatic or peripancreatic necrosis

Appears as non-enhancing area

Early CECT may underestimate (wait 48-72h)

Classification of Acute Pancreatitis

Mild Acute

No organ failure, local or systemic complications. Symptoms improving, able to eat by 48h after admission.

Moderately Severe

Transient organ failure (OF) <48h AND/OR

Local or systemic complications.

Severe Acute (15-20%)

Persistent organ failure (>48h)

Mortality ~36-50%; higher w infected necrosis

Severity of Pancreatitis

Assess hemodynamic status early and frequently thereafter

Scoring systems are based on patient-specific conditions that increase mortality: age, obesity, comorbid conditions, signs of hypovolemia (BUN, Hct), SIRS, pulmonary effusions/infiltrate

APACHE II most widely used scoring system– score >8 = severe

BISAP – simple, can be done early

BUN, AMS, SIRS, Age>60, pleural effusion

>3 points indicates increased risk of death

Ranson’s criteria

Determining Severity

FLUIDS FLUIDS FLUIDS –Early, aggressive hydration with NS or LR

@250-500cc/hr unless cardiac/renal comorbid conditions preclude this

IVF are most beneficial for the first 12-24h; benefit beyond this time is less clear

Frequent reassessment of fluid needs for the first 24-48h

Determine severity and send severe to ICU

Determine etiology – history, LFTs, abdominal US, +/- TGs, Ca

Monitor BUN/Cr, Hct, lytes, LFTs (if initially elevated)

No need for daily lipase; no correlation with severity

Pain management

Nutrition – start oral feeds when pain improving, no ileus in mild dz

Management

In mild AP, early feeding = shorter hospital stay and

starting a low fat, soft diet is as safe as a clear liquid diet

In severe AP, early enteral nutrition (at 24-48 hrs) reduces mortality, multi-system organ failure, infections and need for operative interventions compared to TPN

Maintains intestinal barrier, prevents translocation

NG feedings have been found to be as safe as NJ feedings

Nutrition

ACG – prophylactic antibiotics not recommended

AGA – prophylactic abx should be restricted to pts with >30% pancreatic necrosis by CT and should be used for no more than 14 days

Meropenem or imipenem are drugs of choice

If infected pancreatic necrosis is suspected (pts who deteriorate or fail to improve by 7-10 days), CT-guided FNA with culture can be obtained vs empiric Abx and blood cultures

Antibiotics

Pancreatic necrosis – becomes infected in about 30%; usually

monomicrobial (Ecoli, Pseudomonas, Kleb) Asymptomatic, sterile necrosis does not require intervention If surgical intervention is required, preferable to defer for 4 weeks

until necrosis is walled off

Abscesses Pseudocysts If asymptomatic, need no further intervention Drainage prior to maturation (6 wks) can lead to complications

Splenic vein thrombosis (up to 19% of pts) Anticoagulation may be needed

Abdominal compartment syndrome ARDS, shock, renal failure, GI bleeding

Complications

Early ERCP to remove bile duct stones may decrease severity of

pancreatitis

ERCP within 24 hours in pts with cholangitis

If no cholangitis, but still suspicion for choledocholithiasis, can use MRCP or EUS in place of ERCP

All patients with gallstone panc should have cholecystectomy 25-30% risk of recurrent panc, cholecystitis or cholangitis in <18 wks

Recent retrospective of mild gallstone panc who had lap chole within 48 hrs of admission

No increase in morbidity or mortality

Decreased hospital stay and ERCP

Consider early consult in appropriate patients

Gallstone pancreatitis – early ERCP or surgery?

Early aggressive hydration is critical in the management of

acute pancreatitis

Imaging with contrasted CT or MRI is indicated at 48-72 hrs in pts who are not improving or decompensating

Early enteral nutrition improves outcomes in pts with severe pancreatitis

Key Messages

Banks P et al. Practice Guidelines in Acute Pancreatitis. Am J Gastroenterol 2006;

101:2379-2400 Tenner S et al. Management of Acute Pancreatitis. Am J Gastroenterol 2013;

108:1400–1415 Banks P et al. Classification of acute pancreatitis-2012:revision of the Atlanta

classification and definitions by international consensus. Gut 2013; 62: 102-111. Al-Omran M et al. Enteral versus Parenteral Nutrition for Acute Pancreatitis

(Review). Cochrane Database of Systematic Reviews 2010, Issue1 Falor et al. Early Laparoscopic Cholecystectomy for Mild Gallstone Pancreatitis.

Arch Surg 147: Nov 2012 Van Santvoort et al. Early Endoscopic Retrograde Cholangiopancreatography in

Predicted Severe Acute Biliary Pancreatitis: A Prospective Multicenter Study. Annals of Surgery. 250 (1); July 2009

Wu, Bechien. Prognosis in Acute Pancreatitis. CMAJ: 183 (6); April 2011

References

Original Version: Ashley Duckett, MD and Theresa Cuoco,

MD 2013

Revised 6/11/2015: Stefanie Erway, MD

Revision History