Doctor123.org

Pancreatitis, Emergency Medicine

Basics

Description

- Inflammation of pancreas due to activation, interstitial liberation, and digestion of gland by its ownenzymes - Acute pancreatitis: - Exocrine and endocrine function of gland impaired for weeks to months - Glandular function will return to normal.

- Pancreatic pseudocyst: - Cystic collection of fluid with high content of pancreatic enzymes surrounded by a wall of fibrous tissue lacking a true epithelial lining - Localized in parenchyma of pancreas or adjacent abdominal spaces (lesser peritoneal sac) - Requires 4 " 6 wk to form from onset of acute pancreatitis

- Nausea, vomiting, and anorexia - Bowel sounds usually decreased or absent - Significant GI bleed in patients with acute severe pancreatitis is uncommon. - Cullen sign: - Bluish discoloration at umbilicus secondary to hemorrhagic pancreatitis

- Respiratory: - Pleuritic chest pain - Dyspnea - Lung exam: - Left pleural effusion (most common) - Atelectasis - Pulmonary edema

- Cardiac: - Tachycardia - Hypotension - Shock

- Neurologic: - Irritability - Confusion - Coma - Chvostek and Trousseau signs are rare despite lab evidence of hypocalcemia.

- Criteria during 1st 48 hr: - Hematocrit fall >10% - BUN increase >5 mg/dL - Serum calcium <8 mg/dL - Arterial PO2 <60 mm Hg - Base deficit >4 mEq/L - Estimated fluid sequestration >6 L

- Amylase: - Rises within 6 hr of pain onset - Levels >3 times limit of normal suggest pancreatitis. - Levels >1,000 IU suggest biliary pancreatitis. - May be normal during acute inflammation due to significant pancreatic destruction - Secreted from various sources

  • Inflammation of pancreas due to activation, interstitial liberation, and digestion of gland by its ownenzymes
  • Acute pancreatitis:Exocrine and endocrine function of gland impaired for weeks to monthsGlandular function will return to normal.
  • Chronic pancreatitis:Exocrine and endocrine function progressively deteriorates with resultant steatorrhea and malabsorption.Dysfunction progressive and irreversible
  • Pancreatic pseudocyst:Cystic collection of fluid with high content of pancreatic enzymes surrounded by a wall of fibrous tissue lacking a true epithelial liningLocalized in parenchyma of pancreas or adjacent abdominal spaces (lesser peritoneal sac)Requires 4 " 6 wk to form from onset of acute pancreatitis

Etiology

  • Gallstones and alcohol abuse most common causes of acute pancreatitis (75 " 80%)
  • Alcohol abuse accounts for 70 " 80% of chronic pancreatitis.
  • Acute:Biliary tract diseaseChronic alcoholismObstruction of pancreatic ductIschemiaMedicationsInfectiousPostoperativePost-ERCPMetabolic diseasesTraumaScorpion venomPenetrating peptic ulcerHereditary
  • Chronic:Chronic alcoholismObstruction pancreatic ductTropicalHereditaryShwachman diseaseEnzyme deficiencyIdiopathicHyperlipedemiaHypercalcemia
  • Pancreatic pseudocyst:Complication in 5 " 16% of acute pancreatitis; 20 " 40% of chronic pancreatitis

Causes mainly viral, trauma, and medications

Diagnosis

Signs and Symptoms

  • Frequency:Abdominal pain: 95 " 100%Epigastric tenderness: 95 " 100%Nausea and vomiting: 70 " 90%Low-grade fever: 70 " 85%Hypotension: 20 " 40%Jaundice: 30%Grey Turner/Cullen sign: <5%Subcutaneous or SQ
  • GI:Severe, persistent epigastric pain radiating to back:Colicky or rebound tenderness suggests nonpancreatic source.Worse when supineNausea, vomiting, and anorexiaBowel sounds usually decreased or absentSignificant GI bleed in patients with acute severe pancreatitis is uncommon.Cullen sign:Bluish discoloration at umbilicus secondary to hemorrhagic pancreatitisGrey Turner sign:Bluish discoloration at flank secondary to hemorrhagic pancreatitis
  • Respiratory:Pleuritic chest painDyspneaLung exam:Left pleural effusion (most common)AtelectasisPulmonary edemaHypoxemia (30%)
  • Cardiac:TachycardiaHypotensionShock
  • Neurologic:IrritabilityConfusionComaChvostek and Trousseau signs are rare despite lab evidence of hypocalcemia.

Ranson Criteria

  • Indicators of morbidity and mortality:0 " 2 criteria: 2% mortality3 or 4 criteria: 15% mortality5 or 6 criteria: 40% mortality7 or 8 criteria: 100% mortality
  • Criteria on admission:Age >55 yrWBC count >16,000 mm3Blood glucose >200 mg/dLSerum lactate dehydrogenase >350 IU/LAST >250 IU/L
  • Criteria during 1st 48 hr:Hematocrit fall >10%BUN increase >5 mg/dLSerum calcium <8 mg/dLArterial PO2 <60 mm HgBase deficit >4 mEq/LEstimated fluid sequestration >6 L

Essential Workup

Lab tests to confirm physical diagnosis

Diagnosis Tests & Interpretation

Lab

  • Lipase:Rises within 4 " 8 hr of pain onsetMore reliable indicator of pancreatitis than amylase
  • Amylase:Rises within 6 hr of pain onsetLevels >3 times limit of normal suggest pancreatitis.Levels >1,000 IU suggest biliary pancreatitis.May be normal during acute inflammation due to significant pancreatic destructionSecreted from various sources
  • Electrolyte, BUN, creatinine, glucose:Hypokalemia occurs with extensive fluid losses.Hyperglycemia
  • CBC:Increased hematocrit with fluid lossesHematocrit >47% at risk for pancreatic necrosisDecreased hematocrit with retroperitoneal hemorrhageWBC count >12,000 unusual
  • Calcium/magnesium:Hypocalcemia indicates significant pancreatic injury.Hypomagnesemia occurs with underlying alcohol abuse.
  • Liver function tests:Useful for prognostic indicators if suspected biliary cause
  • CRP:Useful to measure severity at 24 " 48 hr after symptoms onset
  • Pregnancy test
  • Arterial blood gases:Indicated if hypoxic (assess PO2) or toxic appearing (assess base deficit)
  • ECG:Assess electrolyte imbalances, ischemia

Imaging

  • Abdominal series radiograph:Excludes free airMay visualize pancreatic calcificationsMost common finding is isolated dilated bowel loop (sentinel loop) near pancreas.
  • Chest radiograph:Pleural effusionAtelectasisInfiltrate
  • US:Useful if gallstone pancreatitis suspected
  • Abdominal CT indications:High-risk pancreatitis (>3 Ranson criteria)Hemorrhagic pancreatitisSuspicion for pseudocystDiagnosis in doubt

Diagnostic Procedures/Surgery

Endoscopic retrograde cholangiopancreatography (ERCP):

  • Indicated for severe pancreatitis with cholangitis or biliary obstruction

Differential Diagnosis

  • Mesenteric ischemia/infraction
  • Myocardial infarction
  • Biliary colic
  • Intestinal obstruction
  • Perforated ulcer
  • Pneumonia
  • Ruptured aortic aneurysm
  • Ectopic pregnancy

Treatment

Pre-Hospital

  • Initiate IV access in cooperative patients.
  • Apply cardiac monitor.

Initial Stabilization/Therapy

  • ABCs
  • Supplemental oxygen
  • Cardiac monitor
  • IV fluids

Ed Treatment/Procedures

  • Airway management:Pulmonary complaints necessitate supplemental oxygen.Endotracheal intubation for adult respiratory distress syndrome or severe encephalopathy
  • Fluid resuscitation:Large fluid volumes (up to 5 " 6 L in 1st 24 hr) to compensate for fluid lossesContinuously assess vitals, urine output, and electrolytes to ensure rapid and adequate replacement of intravascular volume.
  • Correct electrolyte abnormalities if present:Hypocalcemia (Calcium gluconate)Hypokalemia occurs with extensive fluid losses.Hypomagnesemia occurs with underlying alcohol abuse.
  • Blood products:In hemorrhagic pancreatitis, transfuse to hematocrit level of 30%.Fresh-frozen plasma and platelets if coagulopathic and bleeding
  • Analgesia:Opiate analgesia is the drug of choice.
  • Nasogastric suction:Not useful in cases of mild pancreatitisBeneficial in severe pancreatitis or intractable vomiting
  • Antiemetics
  • Antibiotics:Indicated if pancreatic necrosis >30% on abdominal CT

Consider central venous pressure monitoring when fluid overload is a concern.

Medication

First Line

Analgesics, antiemetics:

  • Morphine 2 " 4 mg IV
  • Hydromorphone (Dilaudid) 1 mg IV/IM
  • Ondansetron 4 mg IV/IM/PO

Second Line

Electrolyte replacement, antibiotics:

  • Potassium chloride: 10 mEq/h IV over 1 hr
  • Calcium gluconate 10%: 10 mL IV over 15 " 20 min
  • Magnesium sulfate: 2 g IV piggyback
  • Imipenem: 500 mg IV q6h

Follow-Up

Disposition

Admission Criteria

  • Acute pancreatitis with significant pain, nausea, vomiting
  • ICU admission for hemorrhagic/necrotizing pancreatitis

Discharge Criteria

  • Mild acute pancreatitis without evidence of biliary tract disease and able to tolerate oral fluids
  • Chronic pancreatitis with minimal abdominal pain and able to tolerate oral fluids

Issues for Referral

  • Surgical/GI consultation for ERCP in severe pancreatitis with cholangitis or biliary obstruction
  • Emergent surgical consultation mandatory in cases of suspected ruptured pseudocyst or pseudocyst hemorrhage, as definitive treatment is emergent laparotomy

Followup Recommendations

All discharged mild pancreatitis should have scheduled follow-up within 24 " 28 hr.

Pearls and Pitfalls

  • Gallstones and alcohol account for etiologies of 75 " 80% of acute pancreatitis.
  • Early aggressive fluid therapy is essential to replace large volume losses.
  • Nasogastric suction is not beneficial in routine pancreatitis.
  • Consider early CT of abdomen when diagnosis in doubt or patient appears ill by clinical scoring scale (Ranson criteria ≥3).

Additional Reading

  • Carroll JK, Herrick B, Gipson T, et al. Acute pancreatitis: Diagnosis, prognosis, and treatment.Am Fam Physician. 2007;75(10):1513 " 1520.
  • Forsmark CE, Baillie J, AGA Institute Clinical Practice and Economics Committee, et al. AGA Institute technical review on acute pancreatitis. Gastroenterology. 2007;132(5):2022 " 2044.
  • Frossard D, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;371:143 " 152.
  • Heinrich S, Sch €fer M, Rousson V, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigm. Ann Surg. 2006;243(2):154 " 168.
  • Whitcomb D. Acute pancreatitis. N Engl J Med. 2006;354:2142 " 2150.

Codes

ICD9

  • 577.0 Acute pancreatitis
  • 577.1 Chronic pancreatitis
  • 577.2 Cyst and pseudocyst of pancreas

ICD10

  • K86.1 Other chronic pancreatitis
  • K85.2 Alcohol induced acute pancreatitis
  • K85.9 Acute pancreatitis, unspecified
  • K85.1 Biliary acute pancreatitis
  • K85.0 Idiopathic acute pancreatitis
  • K85.3 Drug induced acute pancreatitis
  • K85.8 Other acute pancreatitis
  • K85 Acute pancreatitis
  • K86.0 Alcohol-induced chronic pancreatitis
  • K86.3 Pseudocyst of pancreas

SNOMED

  • 75694006 Pancreatitis (disorder)
  • 197456007 Acute pancreatitis (disorder)
  • 235494005 Chronic pancreatitis (disorder)
  • 235942001 Alcohol-induced acute pancreatitis (disorder)
  • 235944000 Drug-induced acute pancreatitis
  • 235952002 Alcohol-induced chronic pancreatitis (disorder)
  • 277537008 post-endoscopic retrograde cholangiopancreatography acute pancreatitis (disorder)
  • 95563007 gallstone pancreatitis (disorder)