Acute pancreatitis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Vendhan Ramanujam M.B.B.S [3]

Overview

Acute pancreatitis is the acute inflammation of the pancreas.

Diagnostic Criteria

▸ Diagnosis is established by the presence of two of the three following criteria (strong recommendation, moderate quality of evidence):[1]

  • Abdominal pain consistent with acute pancreatitis (acute onset of a persistent, severe, epigastric pain often radiating to the back)
  • Serum lipase or amylase ≥ 3 x ULN
  • Characteristic findings on contrast-enhanced computed tomography (CECT), MRI, or transabdominal US

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Acute pancreatitis is a life-threatening condition, especially if it progresses to necrotizing pancreatitis, and should be treated as such irrespective of the cause.

Common Causes

Management

Shown below is a diagram depicting the management of acute pancreatitis according to the American College of Gastroenterology (ACG).[7]

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Severe abdominal pain
❑ Breathing difficulty
❑ Nausea & vomiting
❑ Hiccups sometimes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Fever
❑ Hypotension
Cullen's sign
Grey-Turner's sign
❑ Tachypnea
❑ Abdominal distension and/or tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Gallstones
Dissecting aortic aneurysm
Pancreatic pseudocyst
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess hemodynamic stability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order Labs: (Urgent)
CBC
Hematocrit
BUN
Creatinine
Amylase
Lipase
Triglyceride
❑ Total bilirubin
❑ Direct bilirubin
Albumin
AST
ALT
Alkaline phosphatase
GGT
Chest X-ray
Order imaging studies: (Urgent)
Trans abdominal USG (TAUSG)
 
 
 
 
 
Stabilize the patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria: Any 2 out of 3
❑ Abdominal pain consistent with disease
❑ Serum amylase or lipase values > 3 times normal
❑ Consistent findings from abdominal imaging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute Pancreatitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Systemic inflammatory response syndrome? (Urgent)
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk stratification for organ failure
(Marshall scoring) (Urgent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lower risk
 
 
 
 
 
 
 
 
 
 
 
Higher risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Admit to medical ward
 
 
 
 
 
 
 
 
 
 
 
❑ Admit to ICU (Urgent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluids: (Urgent)

❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs
❑ Reassess within 6 hrs after admission and for next 24-48 hrs

Analgesics: (Urgent)

❑ Opioids are preferred
❑ Mepridine & morphine may be used as IV drips/pt. controlled analgesia


Nutrition: (Urgent)

❑ Immediate oral feeding as soon as pain, vomiting, nausea subside
 
 
 
 
 
 
 
 
 
 
 
Fluids: (Urgent)
❑ Initiate with a fluid bolus
❑ Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs
❑ Reassess within 6 hrs after admission and for next 24-48 hrs

Analgesics: (Urgent)
❑ Opioids are preferred
❑ Mepridine & morphine may be used as IV drips/pt. controlled analgesia


Nutrition: (Urgent)
❑ Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside
❑ Consider enteral feeding if above not tolerated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholangitis or biliary obstruction
 
 
 
 
 
Yes
 
 
 
 
❑ ERCP within 24 hrs/Cholecystectomy to prevent recurrence
Click here for more details
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider MRCP/EUS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical improvement within 48-72 hrs
 
 
 
 
 
Yes
 
 
 
 
❑ Assess for ability to maintain oral feeding at the end of 1 week
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
N o
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ CECT/MRI
 
 
 
 
 
 
 
 
 
 
 
 
Recovery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pancreatic necrosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Failure to improve clinically after 7-10 days of hospitalization
 
 
 
 
 
Yes
 
 
 
 
❑ Supportive treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspected infected necrosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ CT guided FNA

❑ Empiric antibiotics, necrosis penetrating:

❑ Meropenem 1g IV Q8h
❑ Ciprofloxacin 400mg IV Q12h plus metronidazole 500 mg IV Q8h for 14 days
 
 
 
 
Gram stain & Culture (-)
 
 
 
 
❑ Supportive treatment
❑ Consider repeat CT FNA every 7 days if no improvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gram stain & Culture(+)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infected necrosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinically stable
 
 
 
 
 
 
 
 
 
 
 
Clinically unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue antibiotics & observe
❑ If asymptomatic no debridement, else consider surgical consultation
 
 
 
 
 
 
 
 
 
 
 
Prompt surgical consultation (Urgent)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; CBC: Complete blood count; CECT: Contrast-enhanced computed tomography; CT: Computed tomography; ERCP: Endoscopic retrograde cholangiopancreatography; EU: Endoscopic ultrasound; FNA: Fine-needle aspiration; GGT: Gamma-glutamyl transpeptidase; ICU: Intensive care unit; IV: Intravenous; MRCP: Magnetic resonance cholangiopancreatography; MRI: Magnetic resonance imaging; Q8h: Every 8 hours; Q12h: Every 12 hours

Modified Marshall Scoring System

Modified Marshall Scoring System
Organ System 0 1 2 3 4
Respiratory
PaO2/FiO2
>400 301-400 201-300 101-200 ≤101
Renal
Creatinine (μmol/l)
Creatinine (mg/dl)
≤134
<1.4
134-169
1.4-1.8
170-310
1.9-3.6
311-439
3.6-4.9
>439
>4.9
Cardiovascular
Systolic Blood Pressure (mmHg)
>90 <90, fluid responsive <90, not fluid responsive <90, pH <7.3 <90, pH <7.2

A score of 2 or more in any system defines the presence of organ failure.
A score for patients with pre-existing chronic renal failure depends on the extent of further deterioration of baseline renal function. No formal correction exists for a baseline creatinine ≥134 μmol/l or ≥1.4 mg/dl.

For non-ventilated patients, the FiO2 can be estimated from below:

Supplemental oxygen (l/min) FiO2 (%)
Room air 21
2 25
4 30
6–8 40
9–10 50

Grades of Severity

The definitions of severity in acute pancreatitis according to the revised Atlanta classification is as follows.[1]

  • Mild acute pancreatitis
▸ No organ failure
▸ No local or systemic complications
  • Moderately severe acute pancreatitis
▸ Organ failure that resolves within 48 h (transient organ failure) and/or
▸ Local or systemic complications without persistent organ failure
  • Severe acute pancreatitis
▸ Persistent organ failure (>48 h)
– Single organ failure
– Multiple organ failure

Do's

  • Patients who fail to improve clinically (e.g., persistent abdominal pain, fever, nausea, unable to begin oral intake) within the first 48-72 h after admission.
  • Patients in whom the diagnosis is unclear.

Dont's

References

  1. 1.0 1.1 Banks, PA.; Bollen, TL.; Dervenis, C.; Gooszen, HG.; Johnson, CD.; Sarr, MG.; Tsiotos, GG.; Vege, SS.; Acosta, JM. (2013). "Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.". Gut. 62 (1): 102–11. PMID 23100216. doi:10.1136/gutjnl-2012-302779.  Unknown parameter |month= ignored (help)
  2. Yang, AL.; Vadhavkar, S.; Singh, G.; Omary, MB. (2008). "Epidemiology of alcohol-related liver and pancreatic disease in the United States.". Arch Intern Med. 168 (6): 649–56. PMID 18362258. doi:10.1001/archinte.168.6.649.  Unknown parameter |month= ignored (help)
  3. Forsmark, CE.; Baillie, J. (2007). "AGA Institute technical review on acute pancreatitis.". Gastroenterology. 132 (5): 2022–44. PMID 17484894. doi:10.1053/j.gastro.2007.03.065.  Unknown parameter |month= ignored (help)
  4. Fortson, MR.; Freedman, SN.; Webster, PD. (1995). "Clinical assessment of hyperlipidemic pancreatitis.". Am J Gastroenterol. 90 (12): 2134–9. PMID 8540502.  Unknown parameter |month= ignored (help)
  5. Yi, GC.; Yoon, KH.; Hwang, JB. (2012). "Acute Pancreatitis Induced by Azathioprine and 6-mercaptopurine Proven by Single and Low Dose Challenge Testing in a Child with Crohn Disease.". Pediatr Gastroenterol Hepatol Nutr. 15 (4): 272–5. PMID 24010098. doi:10.5223/pghn.2012.15.4.272.  Unknown parameter |month= ignored (help)
  6. Köhler, H.; Lankisch, PG. (1987). "Acute pancreatitis and hyperamylasaemia in pancreatic carcinoma.". Pancreas. 2 (1): 117–9. PMID 2437571. 
  7. Tenner, S.; Baillie, J.; DeWitt, J.; Vege, SS. (2013). "American College of Gastroenterology guideline: management of acute pancreatitis.". Am J Gastroenterol. 108 (9): 1400–15; 1416. PMID 23896955. doi:10.1038/ajg.2013.218.  Unknown parameter |month= ignored (help)
  8. Arvanitakis, M.; Delhaye, M.; De Maertelaere, V.; Bali, M.; Winant, C.; Coppens, E.; Jeanmart, J.; Zalcman, M.; Van Gansbeke, D. (2004). "Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis.". Gastroenterology. 126 (3): 715–23. PMID 14988825.  Unknown parameter |month= ignored (help)
  9. Zaheer, A.; Singh, VK.; Qureshi, RO.; Fishman, EK. (2013). "The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines.". Abdom Imaging. 38 (1): 125–36. PMID 22584543. doi:10.1007/s00261-012-9908-0.  Unknown parameter |month= ignored (help)
  10. Bollen, TL.; Singh, VK.; Maurer, R.; Repas, K.; van Es, HW.; Banks, PA.; Mortele, KJ. (2011). "Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis.". AJR Am J Roentgenol. 197 (2): 386–92. PMID 21785084. doi:10.2214/AJR.09.4025.  Unknown parameter |month= ignored (help)



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