Acute PancreatitisMini Lecture

o Establish the Diagnosis of Acute Pancreatitis

o Establish the Etiology of Acute Pancreatitis

o Initial Management of Acute Pancreatitis

All recommendations are based on the latest ACG Management of Acute Pancreatitis guidelines published in 2013.

Objectives

o Diagnosis of Acute Pancreatitis requires at least 2 of 3 from the following criteria:

o Abdominal pain consistent with acute pancreatitis

o Serum amylase or lipase greater than 3 times the upper limit of normal

o Characteristic findings on abdominal imaging

o CT w/ contrast or MRI should be reserved for patients in whom the diagnosis in unclear or fail to improve within 48-72 hours.

A. Diagnosis

47 year-old female with recent mild alcohol intake and no history of prior gallstones or acute pancreatitis presents to ER with epigastric abdominal pain radiating to the back. Lipase is 500 on admission.

o Diagnosis: Met the following 2 of 3 criteria (1) abdominal pain consistent with acute pancreatitis (2) Lipase > 3 times upper limit of normal – therefore, no CT or MR imaging required to establish diagnosis.

Case Vignette

o Transabdominal ultrasound should be performed in ALL patient with acute pancreatitis to assess gallstones as etiology of acute pancreatitis.

o In absence of gallstones or significant alcohol use, obtain serum triglycerides.o If serum triglycerides > 1,000 mg/dL, consider as etiology of acute

pancreatitis.

o In patients > 40 years of age, consider pancreatic tumor in absence of other causes.

o In patients < 30 years of age and +FH of acute pancreatitis in absence of other causes, consider genetic testing for hereditary pancreatitis.

B. Etiology

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o Etiology: As all patients with acute pancreatitis are recommended to get transabdominal ultrasound, a RUQ ultrasound was done which showed cholelithiasis and CBD dilatation without choledocholithiasis. Likely etiology was gallstone pancreatitis with or without a component of alcohol-induced acute pancreatitis.

Case Vignette – cont.

o Various methods exist to assess severity of acute pancreatitis.

o Next slide describes clinical findings associated with a severe course of acute pancreatitis.

o BISAP score is a helpful tool in assessing severity and in-hospital mortality of acute pancreatitis.o BISAP, Ranson’s, APACHE-II and CTSI scores all have similar

prognostic accuracy.

C. Severity Assessment

8Severity Scoring of Acute Pancreatitis

Bedside index of severity in acute pancreatitis (BISAP) score

Presence of organ failure and/or pancreatic necrosis defines Severe Acute Pancreatitis.

Patients with high severity of initial presentation and/or presence of end-organ failure (shock, AKI, altered mental status, respiratory failure, ARDS, etc) should be admitted to ICU.

o Early AND Aggressive IV fluid hydration must be initiated.o How aggressive?

o If severe hypovolemia present, bolus IV fluids initiallyo Then keep maintenance rate of 250 – 500 mL/hr IV fluids

o What kind of IV fluids?o Isotonic crystalloid (NS, LR)o LR may be preferred (conditional recommendation)

o How soon to start?o Early, early, early !!o Most beneficial in the first 12-24 h

o What is my goal with IV fluid hydration?o Decrease BUN (as checked q6h initially)

D. Initial Management

o Management: NPO, IV fluid hydration at 250-500 cc/hr with monitoring BUN q6h with goal of IVF hydration to decrease BUN in the first 12-24 hours.

Case Vignette – cont.