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