Acute Pancreatitis
Ashley Duckett, MD
Theresa Cuoco, MD, FACP
Objectives
1. Identify clinical presentation and etiologies of
acute pancreatitis
2. Recognize the importance of severity of
pancreatitis in determining management and
outcomes
3. Understand the indications for imaging and
antibiotics in acute pancreatitis
Key Messages
• Early aggressive hydration is critical in the
management of acute pancreatitis.
• Imaging with contrasted CT or MRI is indicated
at 48-72 hours in patients with severe disease.
• Early enteral nutrition improves outcomes in
patients with severe pancreatitis.
• Severity scores can be used to triage patients
at risk for complications.
Clinical presentation
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Abdominal pain, distention
Nausea/vomiting (90%)
Fever, tachycardia, shock, coma
Dyspnea (pleural effusion)
Shallow respirations (diaphragmatic irritation)
Jaundice
Grey-Turner’s/Cullen’s 1% - intraabdominal
hemorrhage
Etiologies
• Gallstones- 35-40% (increased ALT >150 is 50% sensitive and 96%
specific) *women
• Alcohol – 30% *men
• Hypertriglyceridemia
• Hypercalcemia
• Post-ERCP -3% of diagnostic, 25% if SOD studies
• Drugs – direct toxic, immunologic, ischemic causes – cocaine, HCTZ
• Genetic mutations
• Trauma
• Infection – Viruses (mumps, hep B, CMV, HIV), Bacteria
(mycoplasma, legionella, salmonella), fungi, parasites
• Idiopathic -15-20%
• Autoimmune (although usually presents mimicking neoplasm)
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•
Scorpion bite
SOD dysfunction? Pancreatic divisum?
Pathophysiology
• Activation of trypsin in acinar cells
– Activating multiple pancreatic digestive enzymes
(synthesized but not secreted)
– Leak into interstitial space and systemic circulation
• Intrapancreatic Inflammation
– Mediated by cytokines/inflammatory markers
– SIRS
• Extrapancreatic Inflammation
– ARDS
– Multiple organ failure (MOF)
• Respiratory, cardiovascular, renal
Diagnosis
• Requires 2 of the following 3 features
1. Characteristic abdominal pain
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Epigastric, band-like radiating to back, assoc n/v
2. Amylase and/or lipase >/= 3 times the upper limit
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Amylase rises in 6-12 hrs, elevated 3-5 days
Lipase sensitivity 85-100%; more specific than amylase
3. Characteristic CECT (contrast enhanced CT) findings
(or MRI/US)
• Edema, peripancreatic fat stranding, necrosis, calcifications,
pancreatic heterogeneity
Imaging
• Plain XR – unremarkable or have “sentinel loop” (localized
ileus) or “colon cutoff sign” in severe disease
• CXR – pleural effusion suggests increased risk of complications
• Abd ultrasound: diffuse, hypoechoic pancreas, useful for
gallstones, not good for necrosis
• CT scan – useful for complications and for severity assessment
– When to CT? indicated if need to assess for necrosis (severe disease)
at 48-72 hours
– Oral and IV contrast preferred (to diagnose necrosis, calcifications,
stones, mass)
• MRCP – best for delineating fluid collections, necrosis, ducts,
looking for choledocholithiasis
Management
• Determine etiology – history, LFTs, TGs, calcium,
abdominal ultrasound for stones
• Determine severity and send severe to ICU
• FLUIDS FLUIDS FLUIDS – Initial bolus, then 250300cc/hr x 48 hours if cardiac fx normal
– Increasing BUN at 24 hrs predicts mortality
• Monitor glucose and lytes (Ca, Mg)
– No daily amylase/lipase; no correlation with severity
• Pain management
• Nutrition – start oral feeds when pain improving, no
ileus in mild dz
Nutrition
• Need for nutrition and pancreatic rest in
severe pancreatitis or anyone NPO > 5 days
• Early enteral nutrition (at 24-48 hrs) reduces
mortality, multi-system organ failure,
infections and need for operative
interventions compared to TPN
– Maintains intestinal barrier, prevents translocation
– High protein, low fat formula
Antibiotics
• ACG – prophylactic antibiotics not recommended
• AGA – abx should be restricted to pts with >30%
pancreatic necrosis by CT and should be used for less
than 14 days
• Meropenem or imipenem are drugs of choice
• CT guided aspiration/culture recommended if
infected pancreatic necrosis is suspected (fevers,
sepsis, increasing WBC)
Classification of Acute Pancreatitis
1. Interstitial edematous
– Acute inflammation of pancreatic parenchyma
and peripancreatic tissue
2. Necrotizing Acute Pancreatitis
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5-10% of patients
Pancreatic or peripancreatic necrosis
Appears as non-enhancing area
Early CECT may underestimate (wait 48-72h)
Severity of Pancreatitis
• Mild Acute
– No organ failure, local or systemic complications
• Moderately Severe
– Transient organ failure (OF) <48h
– Local or systemic complications w/o persistent OF
• Severe Acute
– Persistent organ failure (>48h)
– Mortality ~36-50%; higher w infected necrosis
Severity scores
• Most cases mild, 15-25% severe
• Depends on presence and duration of organ
failure
• Early risk stratification (median time to ICU
transfer is 24 hours after admission)
• APACHE II most widely used – score >8=severe
• BISAP – simple, can be done early
– BUN, AMS, SIRS, Age>60, pleural effusion
• >3 points indicates increased risk of death
• Ranson’s criteria
Ranson’s Criteria
At admission
1. Age > 55
2. WBC > 16
3. Glu > 200
4. AST > 250
5. LDH > 350
At 48 hrs out
1. Ca < 8
2. HCT fall > 10%
3. PO2 < 60
4. BUN increase > 5
5. Base deficit > 4 mEq/L
6. Sequestration of fluids > 6L
Criteria Met
Mortality
0-2
2%
3-4
15%
5-6
40%
7-8
100%
Complications
• Pancreatic necrosis – becomes infected in about 30%;
usually monomicrobial (Ecoli, Pseudomonas, Kleb)
• Abscesses
• Pseudocysts
-Drainage prior to maturation (6 wks) can lead to
complications
• Splenic vein thrombosis (up to 19% of pts)
– Anticoagulation may be needed for complications
• Abdominal compartment syndrome
• ARDS, shock, renal failure, GI bleeding
Definitions of Pancreatic and
Peripancreatic Fluid Collections
• APFC: Acute Peripancreatic Fluid Collection
– Assoc w intersitial panc; no necrosis
– Homogenous; no definable wall; adjac to pancreas
• Pancreatic Pseudocyst
– Well circumscribed, homogenous, with wall
– Maturation usually >4 weeks after acute panc
• ANC: Acute Necrotic Collection
– Only in setting of necrotizing panc
– Heterogenous, no wall, intra and/or extra pancreatic
• WON: Walled Off Necrosis
– Heterogenous, well defined wall, intra/extra
– Maturation >4 weeks after acute necrotizing panc
Gallstone pancreatitis – early ERCP or
surgery?
• Early ERCP or surgery to remove bile duct stones may
decrease severity of pancreatitis
• ERCP within 72 hours in pts with cholangitis OR concern for
stone (stone on imaging, dilated CBD, jaundice, rising LFTs)
• All patients with gallstone panc should have cholecystectomy
– 25-30% risk of recurrent panc, cholecystitis or cholangitis in <18 wks
• Recent retrospective of mild gallstone panc who had lap chole
within 48 hrs of admission
– No increase in morbidity or mortality
– Decreased hospital stay and ERCP
• Consider early consult in appropriate patients
References
• Banks P et al. Practice Guidelines in Acute Pancreatitis. Am J
Gastroenterol 2006; 101:2379-2400
• Banks P et al. Classification of acute pancreatitis-2012:revision of the
Atlanta classification and definitions by international consensus. Gut
2013; 62: 102-111.
• Al-Omran M et al. Enteral versus Parenteral Nutrition for Acute
Pancreatitis (Review). Cochrane Database of Systematic Reviews 2010,
Issue1
• Falor et al. Early Laparoscopic Cholecystectomy for Mild Gallstone
Pancreatitis. Arch Surg 147: Nov 2012
• Van Santvoort et al. Early Endoscopic Retrograde
Cholangiopancreatography in Predicted Severe Acute Biliary Pancreatitis:
A Prospective Multicenter Study. Annals of Surgery. 250 (1); July 2009
• Wu, Bechien. Prognosis in Acute Pancreatitis. CMAJ: 183 (6); April 2011