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.
- 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 lining
- Localized 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 disease
- Chronic alcoholism
- Obstruction of pancreatic duct
- Ischemia
- Medications
- Infectious
- Postoperative
- Post-ERCP
- Metabolic diseases
- Trauma
- Scorpion venom
- Penetrating peptic ulcer
- Hereditary
- Chronic:
- Chronic alcoholism
- Obstruction pancreatic duct
- Tropical
- Hereditary
- Shwachman disease
- Enzyme deficiency
- Idiopathic
- Hyperlipedemia
- Hypercalcemia
- 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 supine
- 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
- Grey Turner sign:
- Bluish discoloration at flank secondary to hemorrhagic pancreatitis
- Respiratory:
- Pleuritic chest pain
- Dyspnea
- Lung exam:
- Left pleural effusion (most common)
- Atelectasis
- Pulmonary edema
- Hypoxemia (30%)
- Cardiac:
- Tachycardia
- Hypotension
- Shock
- Neurologic:
- Irritability
- Confusion
- Coma
- Chvostek and Trousseau signs are rare despite lab evidence of hypocalcemia.
Ranson Criteria
- Indicators of morbidity and mortality:
- 0 " 2 criteria: 2% mortality
- 3 or 4 criteria: 15% mortality
- 5 or 6 criteria: 40% mortality
- 7 or 8 criteria: 100% mortality
- Criteria on admission:
- Age >55 yr
- WBC count >16,000 mm3
- Blood glucose >200 mg/dL
- Serum lactate dehydrogenase >350 IU/L
- AST >250 IU/L
- 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
Essential Workup
Lab tests to confirm physical diagnosis
Diagnosis Tests & Interpretation
Lab
- Lipase:
- Rises within 4 " 8 hr of pain onset
- More reliable indicator of pancreatitis than amylase
- 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
- Electrolyte, BUN, creatinine, glucose:
- Hypokalemia occurs with extensive fluid losses.
- Hyperglycemia
- CBC:
- Increased hematocrit with fluid losses
- Hematocrit >47% at risk for pancreatic necrosis
- Decreased hematocrit with retroperitoneal hemorrhage
- WBC 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 air
- May visualize pancreatic calcifications
- Most common finding is isolated dilated bowel loop (sentinel loop) near pancreas.
- Chest radiograph:
- Pleural effusion
- Atelectasis
- Infiltrate
- US:
- Useful if gallstone pancreatitis suspected
- Abdominal CT indications:
- High-risk pancreatitis (>3 Ranson criteria)
- Hemorrhagic pancreatitis
- Suspicion for pseudocyst
- Diagnosis 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 losses
- Continuously 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 pancreatitis
- Beneficial 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)