acute pancreatitis

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Here is a structured guide in question-answer format for the management of acute pancreatitis:

Diagnosis of Acute Pancreatitis

Q: What criteria are used to diagnose acute pancreatitis?

  • Diagnosis requires at least two of the following three criteria:
    • Acute epigastric pain radiating to the back, often with nausea/vomiting, relieved by sitting up or leaning forward.
    • Imaging findings: Pancreatitis evidence on CT or ultrasound (usually CT is preferred).
    • Elevated amylase or lipase levels: Greater than three times the upper limit of normal.

Etiology of Acute Pancreatitis

Q: What are the most common causes of acute pancreatitis?

  • The two most common causes in the U.S. are:
    • Gallstones
    • Alcohol use

Q: What is the “I GET SMASHED” mnemonic, and what does it represent?

  • This mnemonic helps remember less common causes of pancreatitis:
    • I: Idiopathic
    • G: Gallstones
    • E: Ethanol (alcohol)
    • T: Trauma
    • S: Steroids
    • M: Mumps or malignancy
    • A: Autoimmune pancreatitis
    • S: Scorpion sting
    • H: Hypertriglyceridemia (>1000 mg/dL) or hypercalcemia (>15 mg/dL)
    • E: ERCP (post-procedure complication)
    • D: Drugs (such as certain antibiotics, antiretrovirals, etc.)

Initial Treatment of Acute Pancreatitis

Q: What are the mainstays of initial treatment for acute pancreatitis?

  • Aggressive fluid resuscitation: To address hypovolemia due to capillary leak.
    • Example protocol: 1 liter of Lactated Ringers (LR) in the first hour, then 250 mL/hr of LR for the next 12 hours, followed by maintenance fluids.
  • Adequate pain control:
    • Typically with opioids, sometimes requiring a PCA (patient-controlled analgesia).
    • Meperidine is noted to possibly cause fewer sphincter of Oddi spasms, although this benefit is not strongly supported by evidence.

Nutritional Management

Q: Should patients with acute pancreatitis be kept NPO (nothing by mouth)?

  • No, NPO is no longer routinely recommended.
    • Early refeeding with a low-fat, low-residue diet or clear liquids can be beneficial and is associated with faster recovery.
    • Advance diet as tolerated to solid foods as quickly as possible.

Antibiotic Use

Q: Are prophylactic antibiotics recommended for acute pancreatitis?

  • No, prophylactic antibiotics are not recommended unless there is a clear source of infection.

Monitoring and Prognosis

Q: What scoring systems are used to predict prognosis in acute pancreatitis?

  • BISAP Score:
    • Factors include BUN, impaired mental status, SIRS criteria, age, and pleural effusion.
  • Ranson's Criteria:
    • Useful for assessing severity but is less commonly used due to complexity.

Q: Why do patients with acute pancreatitis often present with high BUN and hemoglobin levels?

  • This is due to severe volume depletion and hemoconcentration, which also correlate with worse prognosis.

Complications of Acute Pancreatitis

Q: What are common complications of acute pancreatitis?

  • Fluid collections:
    • Acute (<4 weeks): Peripancreatic fluid collection (interstitial) or acute necrotic collection (necrotizing pancreatitis).
    • Chronic (>4 weeks): Pancreatic pseudocyst (interstitial) or walled-off necrosis (necrotizing).
    • Fluid collections over 4 weeks develop a defined wall.
  • Other complications:
    • ARDS (acute respiratory distress syndrome)
    • Chronic pancreatitis and possible pancreatic insufficiency
    • Splenic vein thrombosis (often does not require anticoagulation unless extending to the liver or portal vein).

Q: How should complications like infected necrotic collections be managed?

  • If a patient’s condition worsens after 5–7 days, obtain a repeat CT scan to assess for infected necrosis or other complications.
  • Management may include drainage procedures (often endoscopic) or necrosectomy if the collection is symptomatic or infected.

Q: What are Cullen’s and Grey-Turner’s signs, and what do they indicate?

  • Cullen’s sign: Periumbilical ecchymosis.
  • Grey-Turner’s sign: Flank ecchymosis.
    • These are classic findings associated with hemorrhagic pancreatitis.

Uptodate


Introduction to Acute Pancreatitis Management

Q: What is acute pancreatitis, and how severe can it become?

  • Acute pancreatitis is an acute inflammatory process of the pancreas. While overall mortality is around 2%, it can rise to 30% in cases of severe pancreatitis with persistent organ failure.

Classification of Acute Pancreatitis

Q: How is acute pancreatitis classified by type?

  • According to the Atlanta classification, there are two primary types:
    • Interstitial edematous: Inflammation without tissue necrosis.
    • Necrotizing pancreatitis: Involves tissue necrosis within the pancreas or surrounding areas.

Q: What are the categories of severity in acute pancreatitis?

  • Mild: No organ failure or significant complications.
  • Moderately severe: Transient organ failure (<48 hours) or local complications.
  • Severe: Persistent organ failure (>48 hours), affecting one or more organs.

Initial Assessment and Disease Severity

Q: What should be assessed during initial evaluation for disease severity?

  • A clinical examination should assess for:
    • Early fluid loss
    • Organ failure (especially cardiovascular, respiratory, or renal)
    • Systemic inflammatory response syndrome (SIRS) score
  • Labs: CBC, metabolic panel, CRP, and lactate levels help in evaluating severity.

Q: When is an abdominal CT scan recommended initially?

  • Routine CT is not recommended at initial presentation unless there is diagnostic uncertainty; full extent of necrosis is usually seen 72-96 hours after onset.

Intensive Monitoring and Indications for ICU Admission

Q: When should a patient with acute pancreatitis be admitted to the ICU?

  • Patients with severe acute pancreatitis should be admitted to the ICU.
  • ICU admission is also indicated for patients with pancreatitis and any of the following:
    • Pulse <40 or >150 bpm
    • Systolic BP <80 mmHg or MAP <60 mmHg
    • Respiratory rate >35
    • Extreme serum sodium (<110 or >170 mmol/L), potassium (<2.0 or >7.0 mmol/L), glucose (>800 mg/dL), calcium (>15 mg/dL)
    • PaO2 <50 mmHg or pH <7.1 or >7.7
    • Anuria or coma

Q: What other patients might require intensive monitoring?

  • Patients with persistent SIRS (>48 hours), elevated hematocrit (>44%), BUN (>20 mg/dL), or age >60, especially if there is cardiac or pulmonary disease or obesity.

Initial Management

Q: What are the priorities in initial management of acute pancreatitis?

  • Supportive care: Focus on fluid resuscitation, pain control, and nutritional support.

Fluid Replacement

Q: How is fluid resuscitation managed in acute pancreatitis?

  • Early IV hydration is crucial, especially within the first 24-48 hours. Typically, a moderate hydration approach is preferred:
    • 1.5 mL/kg/hour with a 10 mL/kg bolus for hypovolemic patients.
  • Frequent reassessment of fluid needs within the first 6 hours and over the next 24-48 hours is critical, particularly in older adults or those with cardiac/renal disease.

Q: How is adequate fluid replacement determined?

  • Clinical improvement in:
    • Vital signs: Heart rate <120 bpm, MAP between 65-85 mmHg, urine output >0.5 to 1 cc/kg/hour.
    • Lab markers: Reduction in hematocrit to 35-44% and BUN, especially if high at onset.

Pain Control

Q: What is the recommended approach for pain management in acute pancreatitis?

  • IV opioids are typically used, often through PCA pumps. Options include:
    • Hydromorphone or fentanyl (often preferred due to safety in renal impairment).
  • Meperidine was once favored but is generally avoided now due to potential neuromuscular side effects.

Monitoring

Q: What should be monitored closely in the first 24-48 hours?

  • Vital signs: Including oxygen saturation, with supplemental oxygen as needed.
  • Urine output: Hourly, aiming for >0.5 cc/kg/hour.
  • Electrolytes: Frequently, especially if aggressive fluid resuscitation is being done.
  • Blood glucose: Hourly in severe cases, with treatment for hyperglycemia if needed.
  • Abdominal compartment syndrome: In the ICU, monitor bladder pressures to assess risk.

Nutritional Support

Q: When should oral feeding be resumed in patients with acute pancreatitis?

  • Mild cases: Start a soft, low-residue, low-fat diet early (within 24 hours) if tolerated.
  • Moderately severe to severe cases: Use enteral nutrition via nasojejunal tube if oral intake is not possible by day 5.

Indications for Imaging Follow-Up

Q: When is follow-up imaging recommended?

  • Patients with severe pancreatitis or those showing signs of sepsis or clinical decline after 72 hours should undergo contrast-enhanced CT to assess complications.

Complications Management

Q: What are the common local complications of acute pancreatitis?

  • Local complications include:
    • Acute peripancreatic fluid collection, usually asymptomatic and often resolves.
    • Pancreatic pseudocyst, typically occurs more than 4 weeks after onset.
    • Acute necrotic collection and walled-off necrosis, may require intervention if infected.

Q: How is infected necrosis managed?

  • Suspect infection in patients with clinical deterioration or lack of improvement after 7-10 days. Begin empiric antibiotics (e.g., carbapenem, quinolone + metronidazole).
  • Consider delayed drainage or necrosectomy, ideally after four weeks if needed.

Management of Gallstone Pancreatitis

Q: What is the role of ERCP in gallstone pancreatitis?

  • Urgent ERCP (<24 hours) is recommended for patients with cholangitis. In the absence of cholangitis, ERCP is only indicated for biliary obstruction and high clinical suspicion of CBD stones.

Q: When should cholecystectomy be performed in gallstone pancreatitis?

  • After recovery from the acute episode, cholecystectomy is recommended to reduce recurrence risk. It can be done in the same hospitalization if pancreatitis was mild and resolved.

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