Acute Pancreatitis

Snapshot

A 15-year-old boy with severe nodulocystic acne presents to the emergency room for sudden onset epigastric pain radiating to the back, as well as nausea and vomiting. An abdominal computed tomography shows findings concerning for pancreatitis. On further chart review, the physician discovers that he has been taking isotretinoin, and the dermatologist had been monitoring his triglycerides as they were mildly elevated at the last clinical visit. However, the patient reports that he had not only doubled his dose in the last week in an attempt to speed up the process but also had been eating burgers and fries for every meal. Laboratory results show significantly elevated levels of triglycerides in the blood.

Introduction

Clinical definition
- acute inflammation of pancreas and surrounding tissue, often by autodigestion with pancreatic enzyme leakage
Epidemiology
- risk factors
  - gallstones (more common)
  - heavy alcohol use (more common)
  - electrolyte abnormalities
    - ↑ serum calcium
  - ↑ triglycerides
  - trauma
  - drugs
    - thiazides
    - sulfa drugs
    - NRTIs
    - protease inhibitors
  - viral infections
    - mumps
  - autoimmune disease
  - endoscopic retrograde cholangiopancreatography (ERCP)
  - scorpion sting
Pathogenesis
- inflammation is caused by leakage of pancreatic enzymes into pancreatic tissue
- causes autodigestion of pancreas and surrounding tissue
Prognosis
- Ranson criteria predict mortality

Ranson Criteria
Clinical Signs
On Admission	Within 48 hours
Glucose > 200 mg/dLAge > 55 yearsLDH > 350 IU/LWBC > 16,000/mLAST > 250 IU/dL	Calcium < 8.0 mg/dLHematocrit ↓ by >10%PaO2 < 60 mmHgBase deficit > 4 mEq/LBUN ↑ by 5 mg/dLSequestered fluid > 6 L
Mortality
3-4 signs	20% mortality
5-6 signs	40% mortality
7+ signs	100% mortality

Presentation

Imaging

Abdominal radiograph
- findings
  - sentinel loop
    - isolated and dilated loop of bowel seen in inflammatory conditions
Abdominal ultrasound
- indication
  - all patients
  - to assess for gallstones
- findings
  - enlarged pancreas
  - abscess
  - gallstones
Computed tomography (CT) of abdomen and pelvis with contrast
- indications
  - diagnosis uncertain
  - failure to improve clinically
  - presence of Grey Turner or Cullen sign, as this may indicate hemorrhagic pancreatitis
- findings
  - enlarged pancreas
  - necrosis
  - peripancreatic fluid
  - pseudocyst
  - abscess
CT-guided fine needle aspiration
- indications
  - infected necrosis
for Gram stain and culture to guide antibiotic selection

Studies

Serum labs
- ↑ amylase
- ↑ lipase
- ↓ calcium
Diagnostic criteria
- diagnosis by 2 or more of the following
  - acute-onset epigastric pain
  - ↑ serum amylase or lipase to 3x upper limit of normal
imaging suggestive of pancreatitis

Differential

Peptic ulcer disease
- distinguishing factor
also presents with epigastric pain but will not have elevations in pancreatic enzymes

Treatment

Management approach
- remove all offending agents when possible
- treatment will be guided by etiology of pancreatitis
Conservative
- supportive care
  - fluid resuscitation
  - electrolyte repletion
  - analgesia
  - bowel rest but feed as soon as tolerated
  - nasogastric decompression
Medical
- intravenous antibiotics
Surgery
- endoscopic retrograde cholangiopancreatography (ERCP) with eventual cholecystectomy
  - indication
    - gallstone pancreatitis
- surgical debridement
  - indication
symptomatic necrotizing pancreatitis

Complications