inpatient / gastroenterology
Acute Pancreatitis
# Acute Pancreatitis
Checklist
-- ABCs: hypotension/shock, resp distress c/f effusions or ARDS
-- HPI Intake: onset, EtOH use, gallstone symptoms, procedures, infectious sxs, family history
-- Can't Miss: sepsis, ARDS, hemorrage
-- Admission Orders: CXR, strict I/O, decide on bowel rest
-- Initial Treatment to Consider: aggressive fluid resuscitation, replete lytes, pain management
Assessment:
-- History: *** onset, prior events, EtOH use, gallstone dx, procedures, infectious sxs, FH
-- Clinical: *** abd pain, n/v, fevers, constipation
-- Exam: *** distress, tachycardia, jaundice, abdominal pain, guarding, flank/umbilical (Grey Turner / Cullen Sign) eccymoses
-- Data: *** WBC, lipase, CTAP
-- Etiology/DDx: *** EtOH, gallstone, hypertriglyceridemia, anatomic, ERCP, autoimmune, hyperCa
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- CBC, BMP (calcium), LFTs (gallstones, cholangitis), coags, lipase, lipid panel (triglyceride) if new diagnosis
-- CXR if dyspneic or c/f ARDS/effusions
-- CTAP with contrast if severe, not sure of diagnosis, or not improving after 48-72hrs
-- RUQUS to rule out gallstones if not EtOH
-- ERCP if gallstone disease; ideally cholecystectomy prior to discharge
Treatment
-- Fluids: *** 10mL/kg bolus followed by 1.5cc/kg/hr in first 24 hours
-- Pain: *** dilaudid 1mg q4 PRN
-- Diet: *** early PO, advance as tolerated; tube feeds if no PO intake at 5-7 days
-- Nausea: *** ondansetron 4mg q8 PRN
-- Insulin for hypertriglyceridemia
PDF coming soon!
If You Remember Nothing Else
Make the diagnosis with 2 of 3 of clinical presentation, lipase >3x ULN, and imaging. Give fluids (but not too much), pain meds, and shoot for early PO intake as tolerated. If new and not related to EtOH, get a RUQUS and triglyceride level to search for an etiology.
Clinical Pearls
- Diagnosis - 2 of 3 - consistent clinical presentation (epigastric pain, N/V, etc.), lipase >3x ULN, imaging evidence
- Lipase is ~90% sensitive and specific for pancreatitis and there is not much role for amylase anymore
- Complications are often not seen on imaging until a few days after the start of pancreatitis - necrotizing pancreatitis, abscess, pseudocyst, pancreatic hemorrhage
- BISAP score is used to predict mortality and can be done on presentation; RANSON Score is less practical and incorporates data 48 hours into the admission
- Severe pancreatitis is resuscitated like septic shock with resuscitation - however historically patients received 200-300cc/hr for the first 24 hours resulting in a positive fluid balance of 5+ liters in the first day of admission - goal was to protect end-organ perfusion but at the risk of volume overload and associated complications; recent data suggests more conservative fluid administration is just as efficacious, but safer
- Patients overall will benefit from early enteral nutrition - the concern that it will stimulate the pancreas to dump all of the enzymes and lead to liquefactive necrosis is largely a myth
Trials and Literature
- WATERFALL Trial - Aggressive (20 ml/kg bolus + 3 ml/kg/hr) vs Non-Aggresive (10 ml/kg bolus + 1.5 ml/kg/hr) fluid resuscitation in acute pancreatitis - fluid overload resulted in 20.5% vs 6.3% of patients but no difference in the development of moderately severe or severe pancreatitis (NEJM, 2022)
- Acute Pancreatitis: A Review (JAMA, 2021)
- Acute Pancreatitis (NEJM, 2016)
Other Resources
- Clinical Problem Solvers - Acute Pancreatitis Illness Script
- MD Calc - BISAP Score - predicts mortality
- Internet Book of Critical Care - Pancreatitis
