Acute pancreatitis approach

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

Overview

The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition. Cross-sectional imaging modalities may shed light to the local complications associated with acute pancreatitis and minimally invasive surgery may be performed to manage some complications (e.g. pancreatic necrosis).

Approach to Therapy

According to the American college of gastroenterology, following are the guidelines for initial assessment and risk stratification for acute pancreatitis:[1][2][3][4][5][6][7][8][9][10][11][12][13]

Recommendation Evidence Level Strength of Recommendation
Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed Moderate Strong
Risk assessment should be performed to stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting Moderate Conditional
Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible Low Strong
Intrinsic patient related risk factors
Patient characteristics Age >55 years
Obesity (BMI>30kg/m2)
Altered mental status
Comorbid disease
The systemic inflammatory response syndrome (SIRS)

Presence of >2 of the following criteria

Pulse >90 beats/min
Respirations >20/min

or PaCO2 >32mmHg

Temperature >38°C or <36°C
WBC count >12,000 or <4000 cells/mm3

or >10%  immature neutrophils (bands)

Laboratory findings BUN >20 mg/dl 
Rising BUN
HCT >44%
Rising HCT
Elevated creatinine
Radiology findings Pleural effusions
Pulmonary infiltrates
Multiple or extensive extrapancreatic collections 

References

  1. Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955.
  2. Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, Singh VK, Slivka A, Whitcomb DC, Yadav D, Banks PA, Papachristou GI (2012). "Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis". Gastroenterology. 142 (7): 1476–82, quiz e15–6. doi:10.1053/j.gastro.2012.03.005. PMID 22425589.
  3. Brown A, Orav J, Banks PA (2000). "Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis". Pancreas. 20 (4): 367–72. PMID 10824690.
  4. Tran DD, Cuesta MA (1992). "Evaluation of severity in patients with acute pancreatitis". Am. J. Gastroenterol. 87 (5): 604–8. PMID 1595648.
  5. Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW (2006). "Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis". Br J Surg. 93 (6): 738–44. doi:10.1002/bjs.5290. PMID 16671062.
  6. Buter A, Imrie CW, Carter CR, Evans S, McKay CJ (2002). "Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis". Br J Surg. 89 (3): 298–302. doi:10.1046/j.0007-1323.2001.02025.x. PMID 11872053.
  7. Papachristou GI, Muddana V, Yadav D, Whitcomb DC (2010). "Increased serum creatinine is associated with pancreatic necrosis in acute pancreatitis". Am. J. Gastroenterol. 105 (6): 1451–2. doi:10.1038/ajg.2010.92. PMID 20523325.
  8. Heller SJ, Noordhoek E, Tenner SM, Ramagopal V, Abramowitz M, Hughes M, Banks PA (1997). "Pleural effusion as a predictor of severity in acute pancreatitis". Pancreas. 15 (3): 222–5. PMID 9336784.
  9. Funnell IC, Bornman PC, Weakley SP, Terblanche J, Marks IN (1993). "Obesity: an important prognostic factor in acute pancreatitis". Br J Surg. 80 (4): 484–6. PMID 8495317.
  10. Mann DV, Hershman MJ, Hittinger R, Glazer G (1994). "Multicentre audit of death from acute pancreatitis". Br J Surg. 81 (6): 890–3. PMID 8044613.
  11. Mutinga M, Rosenbluth A, Tenner SM, Odze RR, Sica GT, Banks PA (2000). "Does mortality occur early or late in acute pancreatitis?". Int. J. Pancreatol. 28 (2): 91–5. doi:10.1385/IJGC:28:2:091. PMID 11128978.
  12. Johnson CD, Abu-Hilal M (2004). "Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis". Gut. 53 (9): 1340–4. doi:10.1136/gut.2004.039883. PMC 1774183. PMID 15306596.
  13. Lytras D, Manes K, Triantopoulou C, Paraskeva C, Delis S, Avgerinos C, Dervenis C (2008). "Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis?". Pancreas. 36 (3): 249–54. doi:10.1097/MPA.0b013e31815acb2c. PMID 18362837.



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