Acute Pancreatitis

Alex Wiles

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Background

• Common causes: Gallstones (40%), EtOH (30%)
• Other causes: post-ERCP, pancreatic cancer/obstruction, blunt abdominal trauma, hypertriglyceridemia (TG >1000), hypercalcemia, drugs (thiazides, protease inhibitors, azathioprine, 6MP), mumps, Coxsackie, vasculitis, pregnancy, genetic (PRSS1, SPINK1, CFTR), autoimmune (IgG4), scorpion venom
• Several scoring systems:
  • BISAP (BUN >25, Impaired mental status, SIRS, Age >60, Pleural effusion)
    • 0–2 Mortality <2%; 3-5 Mortality >15%
  • APACHE II (MD Calc, several factors)
    • 0–8 Mortality <4%; > 8 Mortality 11–18%

Presentation

• Must have 2 out of the three:
  • Pain characteristic of pancreatitis (sharp, epigastric, radiating to back)
  • Imaging characteristic of pancreatitis (US, CT, MRI)
  • Enzymes (lipase or amylase) >3x ULN (use lipase, much more specific)
  • *If pain is characteristic and lipase > 3x ULN, no need for CT A/P
• Grading Severity:
  • Mild: no organ failure or systemic complications
  • Moderate: transient organ failure (<48 hours)
  • Severe: persistent organ failure (>48 hours)

Evaluation

• Lipase, CBC, CMP, lipid panel, lactate, direct bilirubin
• Obtain RUQ U/S for all pts, evaluates for gallstones
• CT A/P w/ IV contrast if indicated
  • Reserved for patients not improving at 48-72 hour to assess for complications
  • If performed at onset, underestimates severity (necrosis takes 72 hours from onset)

Management

• Fluids, Fluids, Fluids:
  • First 12-24 hrs: IVF at 200 to 500 cc/hr, or 5-10 cc/kg / hr (2.5 –

    4 L within first 24 hrs)

  • Follow HCT and BUN as markers for successful fluid resuscitation
  • Aggressive IVF in first 24 hours reduces both morbidity and mortality
  • Persistent hemoconcentration at 24 hr is associated with necrotizing pancreatitis
• Pain Control:
  • Common starting narcotic regimen is oxycodone 10 mg q6h PRN and hydromorphone 0.5 mg q4h for breakthrough
• Nutrition:
  • NPO but start PO diet as soon as patient can tolerate (even within 24 hours)
  • Clear liquid diet or mechanical soft and advance as tolerated
  • Low fat diet (Fatty acids → CCK → trypsinogen to trypsin)
  • If NPO > 72 hours, attempt PO and if fail, place Dobhoff for enteral nutrition at latest by day five… outcomes with NG/NJ >>> TPN
• Antibiotics:
  • Fever, leukocytosis common, not an indication for ABX as the necrosis is sterile
  • Infection of the necrosis should be suspected with failure to improve 7 days after onset
  • Cefepime + Flagyl or carbapenem
• EUS or IR guided drain for aspirate: can be done on immature collections for diagnostic purposes but typically only done if collection is walled-off—at least 4 weeks
• Endoscopic Intervention (cystogastrostomy) has emerged as first-line therapy for symptomatic pseudocysts or walled-off pancreatic necrosis , with step-up therapy to video assisted retroperitoneal debridement (VARD) or surgery when needed

Additional Information

• If choledocholithiasis on Imaging urgent ERCP for patients with cholangitis or obstructive jaundice, otherwise elective ERCP
• If Intermediate probability for choledocholithiasis MRCP or EUS or (for patients requiring cholecystectomy Intraoperative cholangiogram
• If biliary sludge but no stones on U/S, still consider cholecystectomy (likely microlithiasis)
• Complications:
  • ARDS, abdominal compartment syndrome, AKI, DIC
  • < 4 weeks after pancreatitis: Peripancreatic fluid collection, acute necrotic collection

  • 6 weeks after pancreatitis: Pancreatic pseudocyst, walled-off necrosis (WON)

• Most fluid collections should be followed over time as acute collections can resolve and are unable to be sampled safely with EUS
• Gallstone pancreatitis:
  • All pts should have cholecystectomy once recovered (recurrence is 25-30%) with EGS
  • Performed during initial admission in cases of mild acute pancreatitis