Acute Pancreatitis

 

Introduction

Pancreatitis should always be considered in any patient with epigastric pain. Once the diagnosis is made the severity should be assessed. Severe cases can lead to multi-organ failure. They therefore require aggressive management in a critical care environment.

Severe cases should have a CT scan performed.

Complications

  • Acute – hypovolaemic shock, electrolyte disturbances, septicaemia from translocation of gut bacteria, multiorgan failure (ARDS, DIC, AKI, ALI)

  • Long term – abscess, necrosis, pseudocyst formation, chronic pancreatitis

 
 

Risk Factors

Causes of Acute Pancreatitis are classically remembered by using the I GET SMASHED mnemonic

  • Idiopathic (3rd most common)

  • Gallstones (Most common)

  • Ethanol (2nd most common. 60-90% of Chronic cases)

  • Trauma

  • Steroids

  • Mumps – other viruses, Coxsackie, HIV

  • Autoimmune – SLE, Sjogrens

  • Scorpion bite

  • Hyperlipidaemia, Hypercalcaemia

  • ERCP, Post Operative

  • Drugs – azathioprine, valproate, co-trimoxazole

 

Clinical Features

 

Symptoms

Pain

  • acute onset, constant, epigastric and through to back, relieved by leaning forward, worse on lying down

GI Upset

  • Nausea, vomiting and anorexia

Signs

Abdominal Signs

  • Generalised tenderness esp in epigastrium. Usually voluntary guarding as opposed to rigidity. May be absent bowel sounds if associated ileus

Systemic Signs (indicating severe illness)

  • Fever, tachycardia, Hypotension, Hypoxia, Tachypnoea

Signs of retroperitoneal haemorrhage in haemorrhagic pancreatitis (rare and not sensitive or specific)

  • Cullen’s sign – bruising around umbilicus

  • Grey Turners Sign – bruising along the flanks

 

Differential Diagnosis

 

Biliary

  • Cholelithiasis

  • Choledocholithiasis

  • Cholecystitis

  • Cholangitis

 

Vascular

  • AAA

  • Dissection

  • Visceral artery aneurysm rupture

GIT

  • Gastritis

  • PUD

  • Diverticulitis

  • Appendicitis

  • Mesenteric Ischaemia

 

Cardiac

  • Acute Coronary Syndrome

Liver

  • Acute Hepatitis

 


 

Renal

  • Pyelonephritis

  • Ureteric Colic

 

Clinical Investigations

 
Normal Aorta US.png

Bedside

POCUS

  • out rule AAA, assess for presence of free fluid +/- GB bladder pathology depending on operators experience

Uranalysis, Urinary BHCG, ECG

  • Primarily to out rule other pathology

VBG

  • high lactate and low pH concerning for severe disease. Elevated BM

 
bloods+%2B+pod.jpg

Laboratory

Amylase

  • > 3 times normal is highly suggestive. Can be normal in 10-20% cases. Amylase not specific to pancreatitis. Rises in first 10 hours. Stays elevated for ~ 5 days

FBC + CRP

  • Leucocytosis and elevated CRP are typical

U&E

  • Look for signs of acute kidney injury, HypoK or HypoNa from vomiting

LFT

  • often elevated especially ALP and GGT in gallstone pancreatitis. Albumin helps predict severity

CoAg

  • signs of coagulopathy indicating severe disease

Urinary Amylase

  • has a role in the late presenter as may remain elevated when serum amylase returns to normal. Again not 100% sensitive or specific

interstitial-edematous-pancreatitis.jpg

Radiology

CXR

  • especially if unwell. Presence of effusions or ARDS picture = severe pancreatitis

AXR

  • May have role in out ruling other pathology. Not a routine investigation

Abdominal Ultrasound

  • If concerned regarding biliary pathology

CT Abdomen

  • not usually indicated in mild pancreatitis.

  • Important when diagnosis is uncertain and also in severe cases to identify any complications

Predictors of Severity

 

Glasgow Scoring System can be used in ED to predict severity of pancreatitis. Score > 3 = Severe

Remember it with the mnemonic PANCREAS

  • PaO2 < 8 kPA

  • Age > 55yrs

  • Neutrophils (WCC) > 15

  • Calcium < 2

  • Raised Urea > 16

  • Enzyme (LDH) > 600

  • Albumin < 321

  • Sugar (BM) > 10

Another criteria (Ranson’s) can be used by in patient teams to assess severity at admission and again at 48 hours. These scores can be looked at in more detail on MDCalc

Management and Disposition

 

Initial Resuscitation

  • Supplemental High flow O2 if Hypoxic/?ARDS

  • IV Crystalloid resuscitation titrated to BP and urine output

 

Specific Treatment

  • Treatment is largely supportive. NPO + IV Fluids

  • Treat cause if identifiable

  • IV antibiotic prophylaxis in severe cases

  • Severe cases will need organ support in ICU

  • Surgery, if needed to debride infected necrotic tissue, is usually delayed to ~ 2/52

Symptomatic Treatment

  • IV Opioid titrated to effect. Never been shown to cause spasm of sphincter of Odi

  • IV anti-emetic PRN

 

Disposition

  • Generally admitted under surgical team +/- with ICU input

References

  1. Dunn et al. Chapter 37 : Abdominal Pain – Pancreatitis. The Emergency Medicine Manual, 5th Edition, Vol 1.

  2. Case courtesy of Dr Michael P Hartung, Radiopaedia.org, rID: 67123

This blog was written by Dr. Deirdre Glynn and was last updated in October 2020

Before you go have another look at the clinical case and see if any of your answers have changed.