Pancreas: Acute Pancreatitis

Acute Pancreatitis

Pathogenesis

  • Acute Inflammation of the Pancreas

Causes Mn

  • Gallstones (Most Common) – 40-70%
  • Alcohol (Second Most Common) – 25-35%
  • Post-ERCP
  • Hypertriglyceridemia & Hypercalcemia
  • Genetic or Autoimmune
  • Trauma
  • Medications
  • Infection
  • Idiopathic

Presentation

  • Symptoms:
    • Epigastric Pain Radiating to the Back
    • Nausea/Vomiting
    • Fever
  • Complications:
    • Acute Pancreatic Fluid Collection
    • Pancreatic Pseudocyst
    • Necrosis
    • Infection
    • Organ Failure
    • Pseudoaneurysm
    • Portosplenomesenteric Venous Thrombosis (PSMVT) If Necrotizing
  • Most Common Causes of Death:
    • Early (< 2 Weeks): SIRS & Organ Failure
    • Late (> 2 Weeks): Sepsis

Revised Atlanta Classification

  • CT Criteria of Fluid Collections Seen After Acute Pancreatitis
 TimingFluid DensityWall
Acute Pancreatic Fluid Collection≤ 4 WeeksHomogenousNo Defined
Pancreatic Pseudocyst> 4 WeeksHomogenousWell Defined
Acute Necrotic Collection≤ 4 WeeksHeterogenousNo Defined
Walled-Off Pancreatic Necrosis> 4 WeeksHeterogenousWell Defined
  • Term “Pancreatic Abscess” No Longer Used

Diagnosis

  • Diagnosis Requires ≥ 2 Of:
    • Acute Persistent Severe Epigastric Pain
    • Elevated Lipase/Amylase ≥ 3x Normal
    • CT Characteristic

Severity Classification

  • Mild: No Local/Systemic Complications or Organ Failure
  • Moderate: Local/Systemic Complications or Organ Failure < 48 Hours
  • Severe: Persistent Organ Failure > 48 Hours

Treatment

  • Initial Treatment: Medical (Aggressive IV Fluids & NPO)
  • Considerations:
    • Early Refeeding (≤ 48 Hours) if Stable & Tolerating Diet
      • If Not Tolerating Oral Diet: Give Enteral Nutrition Through Jejunal Feeding Tube
      • *Old Dogma to Give TPN and Avoid Enteral Nutrition Disproven – Increased Mortality
    • Give ABX Only if There is Concern for Infection
      • *Prophylactic ABX Are Not Recommended Regardless of Severity or Necrosis
  • Gallstone Pancreatitis:
    • 25-30% Risk of Recurrence within 6-18 Weeks
    • All Should Undergo Elective Cholecystectomy During the Same Admission
      • Mild-Moderate Pancreatitis: Early (< 48 Hours) OK
      • Severe Pancreatitis: Wait Until Resolved
    • Cholangitis or Signs of Clear Obstruction: ERCP & Sphincterotomy

Acute Pancreatitis 1

Acute Pancreatitis – Prognostic Criteria

BISAP (Bedside Index for Severity in Acute Pancreatitis)

  • BUN > 25
  • Impaired Mentation
  • SIRS ≥ 2
  • Age > 65
  • Pleural Effusion

Ranson Criteria Mn

  • Admission:
    • Glucose > 200
    • Age > 55
    • LDH > 250
    • AST > 250
    • WBC > 16,000
  • Within 48 Hours:
    • Ca < 8
    • Hct Drop > 10%
    • O2 < 60 Arterial
    • BUN > 5 Increase
    • Base Deficit > 4
    • Sequestration of Fluids > 6 L Needed

Mnemonics

Causes of Acute Pancreatitis

  • “I GET SMASHED”
    • Idiopathic
    • Gallstones
    • Ethanol
    • Trauma
    • Steroids
    • Mumps
    • Autoimmune
    • Scorpion Stings
    • High Ca/TG
    • ERCP
    • Drugs

Ranson Criteria

  • Admission Criteria: “GA LAW”
    • Glucose > 200
    • Age > 55
    • LDH > 250
    • AST > 250
    • WBC > 16,000
  • 48 Hour Criteria: “Calvin & HOBBS”
    • Ca < 8
    • Hct Drop > 10%
    • O2 < 60 Arterial
    • BUN > 5 Increase
    • Base Deficit > 4
    • Sequestration of Fluids > 6 L Needed

References

  1. Bédat B, Scarpa CR, Sadowski SM, Triponez F, Karenovics W. Acute pancreatitis after thoracic duct ligation for iatrogenic chylothorax. A case report. BMC Surg. 2017 Jan 23;17(1):9. (License: CC BY-4.0)