Gallstone pancreatitis resident survival guide

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

Synonyms and Keywords: Biliary pancreatitis

Overview

Gallstone pancreatitis is an acute pancreatitis caused by gallstones. Gallstone pancreatitis is suspected when an acute pancreatitis patient with or without previous history of biliary colic or gallbladder related symptoms presents with elevated serum alanine aminotransferase (ALT) levels and evidence of gallstones or common bile duct stones on abdominal ultrasound.

Causes

Life Threatening Causes

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

Common Causes

Management

Shown below is an algorithm depicting the management of gallstone pancreatitis according to the American College of Gastroenterology (ACG)[2] and the Society for Surgery of the Alimentary Tract (SSAT).[3]

 
 
 
 
 
 
 
Characterize the symptoms:
❑ Severe abdominal pain and/or
Breathing difficulty and/or
Nausea & vomiting and/or
Hiccups sometimes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Fever and/or
Hypotension and/or
Cullen's sign and/or
Grey-Turner's sign and/or
Tachypnea and/or
Abdominal distension and/or tenderness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Gallstones
Dissecting aortic aneurysm
Pancreatic pseudocyst
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 hours
❑ Reassess within 6 hours after admission and for next 24-48 hours

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 hours
❑ Reassess within 6 hours after admission and for next 24-48 hours

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ ± Previous history of biliary colic or GB related Sx
❑ Elevated ALT
❑ ± Elevated AST
❑ Gallstones detected during TAUSG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Gallstone pancreatitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild
 
 
 
 
 
 
 
Severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Good surgical candidates
 
Bad surgical candidates
 
 
 
 
 
❑ Continue resuscitative & supportive care
❑ Early ERCP within 24 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Laparoscopic cholecystectomy during index hospitalization[4]
❑ IOC
❑ ± Intra/postoperative ERCP
 
❑ ERCP with endoscopic sphincterotomy
 
 
Presence of infection
 
 
 
Absence of infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Surgical intervention
 
Good surgical candidates
 
Bad surgical candidates
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Delayed cholecystectomy
 
❑ ERCP with endoscopic sphincterotomy
 
 
 
 
 
 
 
 

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; CBC: Complete blood count; ERCP: Endoscopic retrograde cholangiopancreatography; GB: Gallbladder; GGT: Gamma-glutamyl transpeptidase; H/o History of; ICU: Intensive care unit; IOC: Intraoperative cholangiography; IV: Intravenous; Sx: Symptom

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.[5]

  • 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

Dont's

References

  1. 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)
  2. 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)
  3. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease.". J Gastrointest Surg. 16 (11): 2011–25. PMID 22986769. doi:10.1007/s11605-012-2024-1.  Unknown parameter |month= ignored (help)
  4. Uhl, W.; Warshaw, A.; Imrie, C.; Bassi, C.; McKay, CJ.; Lankisch, PG.; Carter, R.; Di Magno, E.; Banks, PA. (2002). "IAP Guidelines for the Surgical Management of Acute Pancreatitis.". Pancreatology. 2 (6): 565–73. PMID 12435871. doi:71269 Check |doi= value (help). 
  5. 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)
  6. Yadav, D.; O'Connell, M.; Papachristou, GI. (2012). "Natural history following the first attack of acute pancreatitis.". Am J Gastroenterol. 107 (7): 1096–103. PMID 22613906. doi:10.1038/ajg.2012.126.  Unknown parameter |month= ignored (help)
  7. Gurusamy, KS.; Davidson, BR. (2010). "Surgical treatment of gallstones.". Gastroenterol Clin North Am. 39 (2): 229–44, viii. PMID 20478484. doi:10.1016/j.gtc.2010.02.004.  Unknown parameter |month= ignored (help)



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