1.9 Acute Pancreatitis

Question 1

Contrast pathology, serology, symptoms, and CT findings for Acute vs Chronic Pancreatitis

Answer 1

• Acute
  
  • Pathology: neutrophilic inflammatory rxn
  • Serology: increased amylase and lipase
  • Sx: Almost always painful crisis
  • CT: swelling, stranding of peripancreatic fat
• Chronic
  
  • Patho: Mononuclear infiltration and fibrosis
  • Serology: Tend to be normal due to pancreatic burnout
  • Sx: Pain btwn asx periods of time
  • CT: Fibrosis, strictures, calcifications

Question 2

What are the 8 main categories of causes of Acute Pancreatitis, and specific examples of these?

Answer 2

• Congenital
  
  • Anomalies, familial, cystic fibrosis, hereditary angioedema
• Toxic
  
  • EtOH, scorpion venom
• Obstructive (pancreatic duct)
  
  • Gallstones, tumor
• Metabolic
  
  • Hypercalcemia, hypertriglyceridemia
• Trauma
  
  • Blunt vs penetrating
• Ischemia
  
  • Shock, low flow
• Drugs
  
  • ERCP contrast, thiazide diuretics, corticosteroids, cyclosporine, azathioprine, sulfonamides, estrogens
• Infections
  
  • HIV, CMV, salmonella

Question 3

Your patient who presents with pancreatitis may have the following symptoms.

What are key markers to look out for in the physical exam?

You take their labs/diagnostics: what do you look for and what do you find?

Answer 3

Presentation

• Abd pain
  
  • Epigastric stabbing, twisting
  • Radiates to back
• Nausea and vomiting
• Low grade fever (inflammation)
• Hemodynamic instability occurs rapidly
  
  • SIRS

Physical Exam

• LUQ pain on palpation, extending to RUQ
  
  • Guarding
• Turn!
  
  • Cullen’s Sign
    
    • Umbilical discoloration
  • Grey-Turner’s sign
    
    • Flank discoloration

Labs:

• Amylase > 100
• Lipase > 24 (more specific)
  
  • Lipase 3x normal indicates pancreatitis
  • Rises in 4-8h
  • Peaks in 24h
• Calcium: low
• Total protein: low
• Bilirubin: elevation may indicate ‘gallstone’ etiology of pancreatitis

Diagnostics:

• CT gold standard
• Abd US can r/o other causes
  
  • Can assess for ductal obstruction
• APACHEII > 7 predict severe acute panc
• Ranson’s criteria s/p 48h

Question 4

Your patient has acute pancreatitis on CT, and you calculate the Ranson’s criteria. How is the scoring broken down, and what’s the interpretation of the score?

Answer 4

• Ranson’s
  
  • On Admission: 1 pt for each
    
    • WBC > 16k
    • Age > 55
    • BG > 200
    • AST > 250
    • LDH > 350
  • Within 48h: 1 pt for each
    
    • Hct < 10% from admission
    • BUN > over 5mg/dL from admission
    • Serum Calcium < 8
    • Arterial pO2 < 60
    • Base deficit > 4
    • Fluid needs over 6L
  • Interpretation
    
    • Score < 3, severe panc unlikely
    • Score > 3, severe panc likely
    • 0-2: 0-3% mortality
    • 3-5: 11-15% mortality
    • >6: 40% mortality

Question 5

Describe the recommendations re: fluid resucitation for acute pancreatitis

Answer 5

• IV fluid to prevent organ hypoperfusion and hypovolemia
  
  • LR 250-500ml/h in first 12-24h
  • Unless CV, renal, or related comorbidities!
• Check fluid requirements Q6h for 24-48h
  
  • Goal of aggressive hydration is to decrease BUN and/or Hct
• Use goal-directed therapy, not judicious fluids
  
  • Risk of abd compartment syndrome and respiratory complications
• Use same strategy as septic shock
  
  • Moderate fluid and pressors as needed
  • MAP goal 65 or above
• LR preferred
  
  • Caution if hyperkalemic, hypercalcemic

Question 6

Apart from fluids, what interventions are available for acute pancreatitis?

Answer 6

• ERCP
• HIDA scan
• EUS
• Gallstone Pancreatitis
  
  • Mild: Cholecystectomy within 2 wks
  • Severe: ERCP within 72h of admission to reduce morbidity and mortality
• Choledocholithiasis
  
  • Single Stage Approach: Laporascopy vs open cholecystectomy with intraoperative MRCP/exploration
  • Two Stage: Pre-op ERCP w/wo EUS, followed by lap or open cholecystectomy
  • Open surgical debridement
• Skunk procedure
  
  • Advance catheters/drains over guidewires into infected area with closed continuous lavage

Question 7

How you gonna manage acute pancreatitis pain?

How bout nutrition?

Answer 7

• Opioids
  
  • IV PCA dilaudid vs fentanyl
• Nutrition
  
  • Modulates exudative stress response
  • Infxtive complications may arise from gut bacteria due to weakening of intestinal barrier
    
    • So feed ‘em!
  • Mild Pancreatitis: mild, low-fat, soft or full if pain is getting better
  • Severe: enteral nutrition preferred over parenteral (NG or NJ)
    
    • Enteral maintains intestinal motility, preserving gut barrier function and minimizing secondary infection

Question 8

What complications do you look out for in your acute panc patient?

Answer 8

• Pseudocysts
• Ileus
• Pleural effusions
• ARDS/ALI
• PE
• Thrombosis - prothrombic effects
• GI hemorrhage - spleen, gastroduodenal, pancreatic duodenal arteries
• Necrotizing pancreatitis
• Shock (hypovolemic vs distributive)
• Acute MI
• Stroke
• Abd compartment syndrome
  
  • 3rd spacing into peritoneal/retroperitoneal cavities
• Chronic pancreatitis

Question 9

When, if ever, will you recommend abx treatment for acute pancreatitis? Describe the treatment

Answer 9

• Abx NOT warrented UNLESS there is abscess or necrosis
• Infected necrosis: require abx
  
  • Pt deteriorating, clinically unstable, septic
  • Increasing WBC and fever
  • Failure to improve
  • Presence of gas within necrosis
• Carbapenem: monotherapy appropriate
  
  • If cannot have carbapenem:
    
    • Quinolone OR ceftazadime OR cefepime
      
      • AND metronidazole
• Necrosectomy
  
  • Should consider if percutaneous drain and conservative mgmt fail

Question 10

Describe monitoring your patient over the first 48h of admission for acute pancreatitis

Answer 10

• VS, SpO2 > 90%
  
  • ABGs
  • Hypoxia: atelectasis vs pleural effusions vs intrapulmonary shunts vs ARDS
• UO > 0.5-1cc/kg/h
• Lytes closely monitored
  
  • Aggressive fluid resuscitation
• Hypocalcemia corrected if
  
  • Ionized calcium low
  • Neuromuscular irratibility
• Risk for abd compartment syndrome