Acute pancreatitis: Difference between revisions

(lipase)
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*Oddi sphincter dysfunction
*Oddi sphincter dysfunction
*Idiopathic (15-20% of cases)
*Idiopathic (15-20% of cases)
===Prognosis===
====APACHE-II====
*Highest sensitivity and specificity in distinguishing mild from severe pancreatitis<ref>Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.</ref>
*Can be used to estimate the risk of ICU mortality based on worse set of labs during a patient's first 24hrs
====CT Severity Index====
A extension of the Balthazar score with stratification of severity based on score.<ref>Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6</ref><ref>Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13[http://pubs.rsna.org/doi/pdf/10.1148/radiol.2233010680 PDF]</ref>
;Balthazar grading of pancreatitis
:'''A''' = normal pancreas - 0
:'''B''' = enlargement of pancreas - 1
:'''C''' = inflammatory changes in pancreas and peripancreatic fat - 2
:'''D''' = ill defined single fluid collection - 3
:'''E''' = two or more poorly defined fluid collections - 4
;Pancreatic necrosis
:none - 0
:less than/equal to 30% - 2
:> 30-50 % - 4
:> 50% - 6
;The maximum score that can be obtained is 10.
:0-3: mild
:4-6: moderate
:7-10: severe
====Ranson criteria====
Consist of 11 parameters. Five of the factors are assessed at admission, and six of the factors are assessed during the next 48 hours. <ref>Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. PubMed PMID: 4834279</ref>
;On admission:
#Age > 55
#WBC > 16,000
#Blood glucose >200mg/dL
#Lactate dehydrogenase >350 U/L
#Aspartate aminotransferase (AST) >250 U/L
;48 hours:
#Hematocrit fall by > 10%
#BUN increase by >5 mg/dL
#Serum Calcium <8 mg/dL
#pO2 < 60mmHg
#Base deficit >4 MEq/L
#Fluid Sequestation > 6L


==Clinical Features==
==Clinical Features==
Line 56: Line 97:


===Work-Up===
===Work-Up===
#Lipase >3x normal limit (sensitivity 100%, specificity 99%<ref>Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.</ref>)
*Lipase >3x normal limit (sensitivity 100%, specificity 99%<ref>Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.</ref>)
#CBC
*CBC
#Chemistry
*Chemistry
#LFT
*LFT
#?Lactate
*?Lactate
#?Triglyceride
*?Triglyceride


===Imaging===
===Imaging===
Line 74: Line 115:
*Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis
*Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis


==Treatment==
==Management==
'''Place the pancreas at rest'''
'''Place the pancreas at rest'''
#NPO (clears is probably ok for mild/moderate cases)
*NPO (clears is probably ok for mild/moderate cases)
#IVF
*IVF
#*Maintain urine output at 0.5 mL/kg
**Maintain urine output at 0.5 mL/kg
#Analgesia
*Analgesia
#Antiemetics
*Antiemetics
#Hypocalcemia
*Hypocalcemia
#*Treat if symptomatic
**Treat if symptomatic
#Glycemic control
*Glycemic control
#Albumin
*Albumin
#*Consider if level <2
**Consider if level <2
#NGT if ileus is present
*NGT if ileus is present
#[[Antibiotics]]<ref>Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev.2003; Issue 4, CD002941.</ref> <ref>Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.</ref><ref>Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31</ref><ref>Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27</ref><ref>Manes G, Rabitti PG, Menchise A, et al. Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem. Pancreas. 2003;27:79–83</ref>
*[[Antibiotics]]<ref>Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev.2003; Issue 4, CD002941.</ref> <ref>Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.</ref><ref>Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31</ref><ref>Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27</ref><ref>Manes G, Rabitti PG, Menchise A, et al. Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem. Pancreas. 2003;27:79–83</ref>
#*Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
**Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
#*Imipenem-cilastatin, meropenem, or (fluoroquinolone + metronidazole)
**Imipenem-cilastatin, meropenem, or (fluoroquinolone + metronidazole)
#ERCP
*ERCP
#*Indicated for retained CBD stones or cholangitis
**Indicated for retained CBD stones or cholangitis
 
==Disposition==
*Discharge
**Mild case + no biliary disease + no systemic complication + tolerating clears
*All other patients should be admitted


==Complications==
==Complications==
Line 101: Line 147:
*Abdominal pseudoaneurysm
*Abdominal pseudoaneurysm
*Intraabdominal hemorrhage
*Intraabdominal hemorrhage
===Systemic===
===Systemic===
*Cardiac dysfunction
*Cardiac dysfunction
Line 110: Line 155:
*Hyperglycemia
*Hyperglycemia
*Pleural effusion with high amylase
*Pleural effusion with high amylase
==Disposition==
*Discharge
**Mild case + no biliary disease + no systemic complication + tolerating clears
*All other patients should be admitted
==Prognosis==
===APACHE-II===
*Highest sensitivity and specificity in distinguishing mild from severe pancreatitis<ref>Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.</ref>
*Can be used to estimate the risk of ICU mortality based on worse set of labs during a patient's first 24hrs
===CT Severity Index===
A extension of the Balthazar score with stratification of severity based on score.<ref>Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6</ref><ref>Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13[http://pubs.rsna.org/doi/pdf/10.1148/radiol.2233010680 PDF]</ref>
;Balthazar grading of pancreatitis
:'''A''' = normal pancreas - 0
:'''B''' = enlargement of pancreas - 1
:'''C''' = inflammatory changes in pancreas and peripancreatic fat - 2
:'''D''' = ill defined single fluid collection - 3
:'''E''' = two or more poorly defined fluid collections - 4
;Pancreatic necrosis
:none - 0
:less than/equal to 30% - 2
:> 30-50 % - 4
:> 50% - 6
;The maximum score that can be obtained is 10.
:0-3: mild
:4-6: moderate
:7-10: severe
===Ranson criteria===
Consist of 11 parameters. Five of the factors are assessed at admission, and six of the factors are assessed during the next 48 hours. <ref>Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. PubMed PMID: 4834279</ref>
;On admission:
#Age > 55
#WBC > 16,000
#Blood glucose >200mg/dL
#Lactate dehydrogenase >350 U/L
#Aspartate aminotransferase (AST) >250 U/L
;48 hours:
#Hematocrit fall by > 10%
#BUN increase by >5 mg/dL
#Serum Calcium <8 mg/dL
#pO2 < 60mmHg
#Base deficit >4 MEq/L
#Fluid Sequestation > 6L


==See Also==
==See Also==

Revision as of 03:31, 12 March 2016

Background

  • Acute inflammatory process that may involve surrounding tissue and remote organ systems
  • Disease can range from mild inflammation to severe necrosis and multi-organ failure

Etiology

  • Gallstones (including microlithiasis) - 35-40% of cases
  • Alcohol (acute and chronic consumption)
  • Hypertriglyceridemia
  • ERCP
    • Most common post-ERCP complication, usually from mechanical injury from instrumentation of the pancreatic duct or hydrostatic injury from contrast injection
  • Drugs (Azathioprine, cisplatin, furosemide, tetracycline, thiazides, sulfa, valproate, didanosine, pentamidine, etc)
  • Autoimmune disease (SLE, Sjögren, etc)
  • Abdominal trauma
  • Postoperative complications
  • Infection
  • Hypercalcemia
  • Hyperparathyroidism
  • Ischemia
  • Posterior penetrating ulcer
  • Scorpion venom
  • Organophosphate insecticide
  • Pancreatic or ampullary tumor
  • Pancreas divisum with ductular narrowing on pancreatogram
  • Oddi sphincter dysfunction
  • Idiopathic (15-20% of cases)

Prognosis

APACHE-II

  • Highest sensitivity and specificity in distinguishing mild from severe pancreatitis[1]
  • Can be used to estimate the risk of ICU mortality based on worse set of labs during a patient's first 24hrs

CT Severity Index

A extension of the Balthazar score with stratification of severity based on score.[2][3]

Balthazar grading of pancreatitis
A = normal pancreas - 0
B = enlargement of pancreas - 1
C = inflammatory changes in pancreas and peripancreatic fat - 2
D = ill defined single fluid collection - 3
E = two or more poorly defined fluid collections - 4
Pancreatic necrosis
none - 0
less than/equal to 30% - 2
> 30-50 % - 4
> 50% - 6
The maximum score that can be obtained is 10.
0-3: mild
4-6: moderate
7-10: severe

Ranson criteria

Consist of 11 parameters. Five of the factors are assessed at admission, and six of the factors are assessed during the next 48 hours. [4]

On admission
  1. Age > 55
  2. WBC > 16,000
  3. Blood glucose >200mg/dL
  4. Lactate dehydrogenase >350 U/L
  5. Aspartate aminotransferase (AST) >250 U/L
48 hours
  1. Hematocrit fall by > 10%
  2. BUN increase by >5 mg/dL
  3. Serum Calcium <8 mg/dL
  4. pO2 < 60mmHg
  5. Base deficit >4 MEq/L
  6. Fluid Sequestation > 6L

Clinical Features

  • Pain
    • Persistent
    • Localizes to epigastric area, around waist, RUQ, or occasionally LUQ
    • Radiates to back
  • N/V noted in most
  • Abd distention is frequent complaint
  • Cullen sign (ecchymosis of periumbilical region) - intrabdominal hemorrhage
  • Turner sign (ecchymosis of flanks) - retroperitoneal hemorrhage
  • Pulmonary Findings
    • Hypoxemia, ARDS, tachypnea
    • Indicates severe pancreatitis
      • Diaphragmatic inflammation, pancreatico-pleural fistula

Differential Diagnosis

Epigastric Pain


Diffuse Abdominal pain

Diagnosis

Two of the following:

  • Characteristic abdominal pain
  • Lipase level 3x upper limit of normal
  • Negative lipase does not exclude pancreatitis in chronic/recurrent disease
    • Absolute value not associated w/ prognosis or severity
  • Characteristic findings on US or CT

Work-Up

  • Lipase >3x normal limit (sensitivity 100%, specificity 99%[5])
  • CBC
  • Chemistry
  • LFT
  • ?Lactate
  • ?Triglyceride

Imaging

Ultrasound

  • Edematous, swollen pancreas
  • Gallstones
  • Pseudocyst / pancreatic abscess

CT w/ IV contrast [6]

  • Little utility early on in disease and unlikely to affect the management of patients with acute pancreatitis during the first week of the illness
  • Should be reserved for patients with persisting organ failure, severe pain and signs of sepsis

ERCP

  • Indicated for pts w/ severe biliary pancreatitis w/ retained CBD stone or cholangitis

Management

Place the pancreas at rest

  • NPO (clears is probably ok for mild/moderate cases)
  • IVF
    • Maintain urine output at 0.5 mL/kg
  • Analgesia
  • Antiemetics
  • Hypocalcemia
    • Treat if symptomatic
  • Glycemic control
  • Albumin
    • Consider if level <2
  • NGT if ileus is present
  • Antibiotics[7] [8][9][10][11]
    • Only indicated for necrosis, abscess, or infected pseudocyst / peripancreatic fluid
    • Imipenem-cilastatin, meropenem, or (fluoroquinolone + metronidazole)
  • ERCP
    • Indicated for retained CBD stones or cholangitis

Disposition

  • Discharge
    • Mild case + no biliary disease + no systemic complication + tolerating clears
  • All other patients should be admitted

Complications

Local

  • Pancreatic necrosis
  • Pancreatic pseudocyst / abscess
  • Portal vein thrombosis
  • Abdominal compartment syndrome
  • Abdominal pseudoaneurysm
  • Intraabdominal hemorrhage

Systemic

  • Cardiac dysfunction
  • Renal failure
  • Respiratory failure
  • Shock
  • Hypocalcemia (due to sequestration in necrotic fat)
  • Hyperglycemia
  • Pleural effusion with high amylase

See Also

Pancreatitis Guidelines

External Links

References

  1. ↑ Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
  2. ↑ Balthazar EJ, Robinson DL, Megibow AJ et-al. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174 (2): 331-6
  3. ↑ Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223 (3): 603-13PDF
  4. ↑ Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974 Jul;139(1):69-81. PubMed PMID: 4834279
  5. ↑ Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. 2002 Jun;97(6):1309-18.
  6. ↑ UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005;54:iii1-iii9
  7. ↑ Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev.2003; Issue 4, CD002941.
  8. ↑ Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.
  9. ↑ Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31
  10. ↑ Zhou YM, Xue ZL, Li YM, et al. Antibiotic prophylaxis in patients with severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2005;4:23–27
  11. ↑ Manes G, Rabitti PG, Menchise A, et al. Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem. Pancreas. 2003;27:79–83
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