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Acute pancreatitis

Acute pancreatitis is acute inflammation of the pancreas, and can range from mild inflammation to severe extensive pancreatic necrosis, and may be associated with multi-organ failure. The majority of cases are mild with a mortality rate <1% and resolve with supportive care. Severe pancreatitis has mortality rates over 20%. There is no pathognomonic clinical presentation and no diagnostic gold standard, hence diagnosis can be difficult.


Step 1: Pathway Entry

Symptoms to consider: Abdominal pain-upper or generalised, typically severe, may radiate to back. Other common symptoms to consider include nausea, vomiting and diaphoresis.

Signs to consider: Abdominal tenderness, abdominal distension.

In severe pancreatitis-hypotension, a bluish discolouration around the umbilicus (Cullen's sign) or the flank (Grey–Turner's sign) is sometimes associated with haemorrhagic pancreatitis (a late, serious complication).

Risk Factors to consider:

Common:

  • Gallstones (50% of cases)
  • Ethanol (20-25%)

Others:

  • Endoscopic procedures (complicates up to 10% of ERCP)
  • Trauma
  • Infections-viral, bacterial, fungal and parasitic
  • Autoimmune diseases
  • Metabolic: Hypercalcaemia, hyperlipidaemia, hypothermia
  • Vascular: vasculitis, ischaemia, embolism
  • Genetic
  • Pancreatitis may be idiopathic

Step 2: Is the Patient Stable?

Initiate resuscitation measures if required.

Consideration of other life-threatening diagnoses with similar symptoms

  • ACS
  • Aortic Dissection
  • Perforated viscus
  • Oesophageal Rupture
  • Pancreatitis
  • Ectopic Pregnancy
  • AAA

Step 3: Detailed Initial Assessment

In the stable patient a thorough assessment is the next step including a detailed history, a detailed examination, blood tests including FBC, EUC, LFTs, lipase, BSL, an ECG and a CXR. Beta-HCG in women of childbearing age.

If an alternative diagnosis is made at this time then the steps further down the pathway can be curtailed.


Step 4: Diagnosis

Serum lipase three times the upper limit of normal is suggestive of pancreatitis (82-100% sensitive). Lipase remains elevated for a longer period of time and has a higher specificity as compared with amylase. However, a normal serum lipase level does not exclude the diagnosis of pancreatitis, especially with recurrent disease, if the clinical features are compatible with the diagnosis. Also, the lipase level is not predictive of the severity or outcome of disease.


Step 5: Risk stratification

Acute pancreatitis is an evolving dynamic condition and the severity may change during the course of the illness. Early in the disease, SIRS or organ failure indicate potentially severe disease. Essentially the aim in ED is to identify severe pancreatitis (or potentially severe disease) so that earlier aggressive management may be instituted.

  • Mild acute pancreatitis
    • No organ failure
    • No local or systemic complications
  • Moderately severe acute pancreatitis
    • No organ failure or transient organ failure (resolves within 48 hours) and/or
    • Local complications
  • Severe acute pancreatitis
    • Persistent organ failure (>48 hours) that involves single or multiple organs

Various risk stratification scores exist which require information on admission and within 48 hours of admission, hence use in ED is limited. One of the simpler scoring systems is the Modified Glasgow Score. This suggests severe pancreatitis if any three of the following criteria are found.

Modified Glasgow Score (mnemonic PANCREAS) - 1 point for each present

  • P02 Oxygen <60mmHg
  • Age >55 years
  • Neutrophilia WCC count >15
  • Calcium <2mmol/L
  • Renal - Urea >16mmol/L
  • Enzymes Lactate dehydrogenase (LDH) >600iu/L, Aspartate transaminase (AST) >200IU/L
  • Albumin <32g/L
  • Sugar Glucose >10 mmol/L

A score ≥3 suggests severe pancreatitis and referral to HDU/ICU should be considered.

If there is any other sign of organ dysfunction present, (such as hypotension), one should have a low threshold for referral to HDU/ICU.


Step 6: Imaging

CXR: To exclude differentials (eg free subdiaphragmatic air in perforated viscus, consolidation) and to look for complications (ARDS, pleural effusion)

AXR: Not routinely done, to exclude obstruction if a differential, if done may show localized ileus of a segment of small intestine (sentinel loop) or the colon cutoff sign in more severe disease

Ultrasound: Early ultrasound recommended. May diagnose pancreatitis, gallstones, pancreatic pseudocyst. In approximately 25 to 35 percent of patients with acute pancreatitis, bowel gas due to an ileus precludes evaluation of the pancreas or bile duct

Contrast enhanced CT may be used for diagnosis if clinical and biochemical findings unclear, especially if alternative surgical emergency is considered. Not routine to perform early CT for assessing severity of acute pancreatitis.


Step 7: Management

  • Supportive care
    • Analgesia
    • IV fluid with monitoring of fluid input and output (4 litres over first 24 hours unless
  • Seek and treat cause
  • No role for routine prophylactic antibiotics
  • PPI/ VTE prophylaxis
  • Early enteral feeding
  • Seek and treat complications (see Step 8)

In the initial stages (within the first 12 to 24 hours) of acute pancreatitis, fluid replacement has been associated with a reduction in morbidity and mortality. Unless contraindicated for another reason (e.g. severe heart failure) aim for 4 litres of crystalloid over 24 hours.


Step 8: Seek and treat complications

Local complications

  • Pancreatic necrosis
  • Pancreatic pseudocyst
  • Pancreatic abscess
  • Fistulae

Systemic complications

  • SIRS/sepsis
  • myocardial depression
  • shock
  • renal failure
  • respiratory failure (ARDS, pleural effusions, atelectasis)
  • pain
  • metabolic derangement
  • ileus
  • death

Further References and Resources

Online resources

  1. BMJ Best Practice - acute pancreatitis (requires login)
  2. Up to date resources (requires login): Management of of acute pancreatitis

Journal articles and textbooks

  1. Banks PA, Bollen TL, Dervenis C, Goozen HG, Johnson CD, Sarr MG, Tsuitis GG, Vege SS, Acute Pancreatitis Classification Working Group, 'Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus'Gut, January 2013, vol. 62, no. 1, pp. 102-111.
  2. Tintinalli, Judith E, Tintinalli's emergency medicine : a comprehensive study guide, 7TH edition, Chapter 82: Pancreatitis and Cholecystitis
  3. UK Working Party on Acute Pancreatitis, 'UK guidelines for the management of acute pancreatitis'Gut, May 2005, vol. 54, Suppl III, iii1–iii9.
  4. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Working Group IAP/APA Acute Pancreatitis Guidelines Pancreatology. 2013 Jul;13(4 Suppl 2):e1-e15

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