Pancreatitis

Question 1

A 42-year-old male patient is admitted to intensive care with severe pancreatitis. He has a history of hypertension, chronic back pain and alcohol excess.

How is a diagnosis of severe pancreatitis made?

Answer 1

• A diagnosis of pancreatitis requires two of the following three criteria to be fulflled:

1. Severe epigastric abdominal pain consistent with a diagnosis of pancreatitis.
2. An increase in serum lipase or amylase at least three times the upper limit of normal.
3. CT abdominal scan findings suggestive of pancreatitis.

• Severe pancreatitis suggests the presence of organ failure or local complications for more than 48 hours, and often requires management on a high dependency or intensive care unit for supportive therapy.

Question 2

What causes Cullen’s sign?

Answer 2

• Cullen’s sign is seen as darkened discolouration and oedema surrounding the umbilicus.
• It is caused by retroperitoneal haemorrhage tracking through subcutaneous fat and abdominal planes.

Question 3

How would you manage this patient on admission to intensive care?

Answer 3

• Take a detailed handover from the parent team including any investigations and treatment.
• Carry out an ABCDE assessment to establish the need for time-critical interventions and escalation of care environment, in consultation with seniors as appropriate.
• Take a thorough medical and social history, examine the patient and ensure appropriate baseline investigations are done including an arterial blood gas, renal function and markers of infection.
• Management of this patient will be largely supportive and should include:
• High flow oxygen and further ventilatory support if indicated.
• Fluid resuscitation due to ongoing insensible losses and intravascular volume depletion.
• Blood pressure support with vasopressors if required.
• Early enteral feeding and ulcer prophylaxis.
• Correction of electrolyte disturbances and blood glucose control.
• Analgesia for patient comfort and to minimise the effect of abdominal pathology on ventilation.
• Consider administering agents to prevent alcohol withdrawal given the patient’s history (chlordiazepoxide is commonly used).

Question 4

What are the complications in patients with severe acute pancreatitis?

Answer 4

Local complications:

• Pancreatic/local fat necrosis.
• Haemorrhagic pancreatitis.
• Pancreatic pseudocyst formation.
• Pancreatic abscess.

Systemic complications:

• Pleural effusion.
• Systemic thromboses e.g. portal vein/splenic vein thrombosis.
• Major abdominal haemorrhage.
• Intra-abdominal hypertension/abdominal compartment syndrome.
• Malnutrition.
• Diabetes mellitus.
• Prolonged stay on intensive care and associated risks.
• Overall increase in morbidity and mortality.

Question 5

The patient deteriorates and requires intubation and ventilation. A week later, his repeat CT scan shows findings suggestive of pancreatic necrosis.

How should he be managed?

Answer 5

• Continue supportive treatment as above.
• Ensure multidisciplinary involvement of the surgical team to ascertain the best course of management.
• Consider parenteral nutrition if not absorbing enteral feeds.
• Any surgical intervention should be delayed until 3–4 weeks after the initial diagnosis due to the increased risk of mortality with early surgery.
• If indicated (for management of suspected infected necrosis or
  abscess) opt for minimally invasive techniques initially if appropriate
  e.g. percutaneous drainage.
• Administer antibiotics only if there is suggestion of infective necrosis
  (liaising with microbiology).

Question 6

What are the long-term consequences of a prolonged stay in intensive care?

Answer 6

• Weakness and loss of muscle mass.
• Sleep disturbance.
• Cognitive dysfunction/decline.
• Anxiety/depression.
• Long-term pathology: chronic kidney disease, heart failure, pulmonary fibrosis.
• Complications of prolonged intubation/tracheostomy e.g. phrenic nerve weakness and tracheal stenosis.
• Chronic pain.
• Chronic pressure sores.