Acute Pancreatitis

Mini Lecture
FARID JALALI

JANUARY 23, 2014

Objectives
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.

A. Diagnosis
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.

Case Vignette
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.

B. Etiology
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.

Case Vignette cont.

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.

C. Severity Assessment
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, Ransons, APACHE-II and CTSI scores all have similar prognostic
accuracy.

Severity 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.

D. Initial Management
o Early AND Aggressive IV fluid hydration must be initiated.
o How aggressive?
o If severe hypovolemia present, bolus IV fluids initially
o 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)

Case Vignette cont.

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.

E. Role of Antibiotics
o Do NOT #1: Routine use of prophylactic antibiotics for severe acute
pancreatitis is NOT recommended.
o Do NOT #2: Use of antibiotics to prevent progression of sterile necrosis to
infected necrosis is NOT recommended.
o Keep in mind that patients with acute pancreatitis often and early have
fever but this does not necessarily mean infected necrosis exists.

E. Role of Antibiotics
o Think of infected necrosis if patient with pancreatic or extra-pancreatic
necrosis fails to improve after 7-10 days of hospitalization.
o In case of infected necrosis, either FNA with gram-stain and culture to
narrow antibiotic regimen or empirically treat with antibacterial
antibiotics.
o Routine antifungal therapy is not recommended unless specifically
indicated based on culture and/or gram-stain.

Case Vignette cont.

o Antibiotics role: Despite spiking one fever to 101 F, no clinical concern for
infected necrosis existed and patient improved clinically within 48 hours. No
antibiotics were therefore initiated.

F. Feeding
o NG versus NJ tube feeding are COMPARABLE in efficacy and safety.
o In other words, do NOT delay enteral feeding because NJ tube is not
present.
o IV nutrition should be avoided unless enteral nutrition is not available, not
tolerated, or not meeting caloric requirements.
o Enteral feeding is not merely to meet caloric requirements; it also prevents
infectious complications.
o Timing of enteral feeding? Not mentioned in guidelines, but generally if
anticipate patient cannot have PO intake within 48 hours, start enteral
feeding with NG or NJ.

Case Vignette cont.

o Enteral feeding: As patient was able to have PO intake within 48 hours,
neither NG nor NJ tube feeding was initiated.

G. Role of Surgery
o Mild acute pancreatitis with gallstones Perform cholecystectomy before
discharge
o Necrotizing acute pancreatitis with gallstones Delay cholecystectomy until
inflammation subsides
o Asymptomatic pseudocysts or sterile necrosis do NOT warrant intervention
(i.e drainage) regardless of size or location.
o Drainage of infected necrosis should be delayed for at least 4 weeks to allow
formation of walled-off necrosis.

Case Vignette cont.

o Role of Surgery: Given evidence of gallstones and mild acute pancreatitis,
cholecystectomy was performed before discharge to prevent recurrent
episodes of gallstones pancreatitis.

Summary
o Early and accurate diagnosis of acute pancreatitis is crucial.
o Early treatment of acute pancreatitis with aggressive IV fluid hydration saves
lives and is most beneficial in the first 12-24 hours.
o Routine prophylactic antibiotic use is not recommended for acute pancreatitis
unless presence of infected necrosis is established clinically or by FNA.
o Mild acute pancreatitis due to gallstones warrants cholecystectomy before
discharge.

References
o

ScottTennerMD, MPH, FACG, JohnBaillieMB, ChB, FRCP, FACG, JohnDeWittMD, FACGand Santhi
SwaroopVegeMD, FACG. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am
J Gastroenterol2013; 108:14001415; doi:10.1038/ajg.2013.218; published online 30 July 2013.