25 Nov

Acute pancreatitis

Definition

Acute pancreatitis is defined as reversible inflammation of the pancreas with no evidence of pancreatic insufficiency

Diagnosis

  1. History
  • Most patient presents with typical epigastrium pain radiating to the back. It is described as dull aching and alleviated upon stooping forward. Physical is usually unremarkable.
  1. Positive Serum Amylase or Lipase
  • Although lipase is more sensitive and specific for diagnosis, it is not available in the most health centre.
  • A diagnosis of acute pancreatitis is confirmed if any of those tests id three times the upper limit.
  1. Imaging consistent with pancreatitis changes
  • The choice of imaging depends on local resources and availability. These modalities include CT scan, MRI or USG
  • A diagnosis using USG requires an experienced physician or technician due to the retroperitoneal position and easily obscured by the bowel gas.

Aetiology (I GET SMASHED)

  • I – Idiopathic
  • G – Gallstone
  • E – Ethanol
  • T – Trauma
  • S – Steroids
  • M – Mumps (includes other infection or malignancy)
  • A – Autoimmune
  • S –Scorpion or spider bites
  • H – hyperlipidaemia/ hypercalcaemia/ other metabolic disorders
  • E – ERCP
  • D – Drugs

Classification

Mild

No local or systemic complications present

Moderate

Evidence of local (peripancreatic fluid collections), systemic (exacerbation of chronic disease) and transient organ failure (<48 hours)

Severe

Evidence of local, systemic and persistent organ failure (>48 hours)

Treatment

Acute phase

Early treatment of acute pancreatitis consists of supportive care which includes fluid resuscitation and pain management.

Fluid resuscitation

Patients with acute pancreatitis have a chance to develop severe fluid extravasation to the third space. Because of this, they can develop hypotension, hypovolaemia, hypoperfusion and organ failure. Hence adequate fluid resuscitation is needed.

The choice of fluid would be crystalloid specifically Ringer’s lactate. However, normal saline is still a reasonable choice in most centres. Key target parameters should be monitored to ensure adequate resuscitation.

  • Urine output of 0.5-1 ml/kg/hr
  • Urea and creatinine level
  • Heart rate and mean arterial pressure.

Pain management

Pain control remains one of the major therapy in acute pancreatitis. The patient should be assessed for pain score frequently so adjustment of the painkiller can be made.

Choices include NSAIDs and strong opioid.

Antibiotics

Antibiotics are not routinely used in the management of acute pancreatitis. However, it is recommended to start in cases such as infected necrotizing pancreatitis and pancreatic abscess. It is also administered in cases of predicted severe pancreatitis. There is no role of prophylaxis antibiotics in acute pancreatitis treatment.

Nutrition

In patients with pancreatitis, oral intake should be started early once the pain subsides regardless of the severity. However, nasoenteric feeding should be considered if the patient is unable to take orally more than 3-5 days.

ERCP

The indication of an ERCP in acute pancreatitis is only when there is concomitant cholangitis. This proves to be useful in reducing the possible sepsis from the biliary obstruction.

Other

In cases where the diagnosis was confirmed by clinical and laboratory tests, imaging is not needed unless another acute pathology is suspected.

Important terminology

Acute fluid collection: Acute peripancreatic and interstitial collections

Acute necrotic collection (ANC): necrotizing pancreatitis

Walled-off necrosis (WON): progression of an ANC. This process takes around 4-6 weeks for maturity. It is important to assess the possibility of infection within this WON

More updates here

 

Leave a Reply