1. Ashley Duckett, MD Theresa Cuoco, MD, FACP
Acute Pancreatitis
Ashley Duckett, MD
Theresa Cuoco, MD, FACP

2. Objectives
Identify clinical presentation and etiologies of acute pancreatitis
Recognize the importance of severity of pancreatitis in determining management and outcomes
Understand the indications for imaging and antibiotics in acute pancreatitis

3. Key Messages
Early aggressive hydration is critical in the management of acute pancreatitis.
Imaging with contrasted CT or MRI is indicated at hours in patients with severe disease.
Early enteral nutrition improves outcomes in patients with severe pancreatitis.
Severity scores can be used to triage patients at risk for complications.

4. Clinical presentation
Abdominal pain, distention
Nausea/vomiting (90%)
Fever, tachycardia, shock, coma
Dyspnea (pleural effusion)
Shallow respirations (diaphragmatic irritation)
Jaundice
Grey-Turner’s/Cullen’s 1% - intraabdominal hemorrhage

5. Etiologies
Gallstones % (increased ALT >150 is 50% sensitive and 96% specific) *women
Alcohol – 30% *men
Hypertriglyceridemia
Hypercalcemia
Post-ERCP -3% of diagnostic, 25% if SOD studies
Drugs – direct toxic, immunologic, ischemic causes – cocaine, HCTZ
Genetic mutations
Trauma
Infection – Viruses (mumps, hep B, CMV, HIV), Bacteria (mycoplasma, legionella, salmonella), fungi, parasites
Idiopathic %
Autoimmune (although usually presents mimicking neoplasm)
Scorpion bite
SOD dysfunction? Pancreatic divisum?

6. Pathophysiology Activation of trypsin in acinar cells
Activating multiple pancreatic digestive enzymes (synthesized but not secreted)
Leak into interstitial space and systemic circulation
Intrapancreatic Inflammation
Mediated by cytokines/inflammatory markers
SIRS
Extrapancreatic Inflammation
ARDS
Multiple organ failure (MOF)
Respiratory, cardiovascular, renal

7. Diagnosis Requires 2 of the following 3 features
Characteristic abdominal pain
Epigastric, band-like radiating to back, assoc n/v
Amylase and/or lipase >/= 3 times the upper limit
Amylase rises in 6-12 hrs, elevated 3-5 days
Lipase sensitivity %; more specific than amylase
Characteristic CECT (contrast enhanced CT) findings (or MRI/US)
Edema, peripancreatic fat stranding, necrosis, calcifications, pancreatic heterogeneity

8. Imaging
Plain XR – unremarkable or have “sentinel loop” (localized ileus) or “colon cutoff sign” in severe disease
CXR – pleural effusion suggests increased risk of complications
Abd ultrasound: diffuse, hypoechoic pancreas, useful for gallstones, not good for necrosis
CT scan – useful for complications and for severity assessment
When to CT? indicated if need to assess for necrosis (severe disease) at hours
Oral and IV contrast preferred (to diagnose necrosis, calcifications, stones, mass)
MRCP – best for delineating fluid collections, necrosis, ducts, looking for choledocholithiasis

9. Management
Determine etiology – history, LFTs, TGs, calcium, abdominal ultrasound for stones
Determine severity and send severe to ICU
FLUIDS FLUIDS FLUIDS – Initial bolus, then cc/hr x 48 hours if cardiac fx normal
Increasing BUN at 24 hrs predicts mortality
Monitor glucose and lytes (Ca, Mg)
No daily amylase/lipase; no correlation with severity
Pain management
Nutrition – start oral feeds when pain improving, no ileus in mild dz

10. Nutrition
Need for nutrition and pancreatic rest in severe pancreatitis or anyone NPO > 5 days
Early enteral nutrition (at hrs) reduces mortality, multi-system organ failure, infections and need for operative interventions compared to TPN
Maintains intestinal barrier, prevents translocation
High protein, low fat formula

11. Antibiotics ACG – prophylactic antibiotics not recommended
AGA – abx should be restricted to pts with >30% pancreatic necrosis by CT and should be used for less than 14 days
Meropenem or imipenem are drugs of choice
CT guided aspiration/culture recommended if infected pancreatic necrosis is suspected (fevers, sepsis, increasing WBC)

12. Classification of Acute Pancreatitis
Interstitial edematous
Acute inflammation of pancreatic parenchyma and peripancreatic tissue
Necrotizing Acute Pancreatitis
5-10% of patients
Pancreatic or peripancreatic necrosis
Appears as non-enhancing area
Early CECT may underestimate (wait 48-72h)

13. Severity of Pancreatitis
Mild Acute
No organ failure, local or systemic complications
Moderately Severe
Transient organ failure (OF) <48h
Local or systemic complications w/o persistent OF
Severe Acute
Persistent organ failure (>48h)
Mortality ~36-50%; higher w infected necrosis

14. Severity scores Most cases mild, 15-25% severe
Depends on presence and duration of organ failure
Early risk stratification (median time to ICU transfer is 24 hours after admission)
APACHE II most widely used – score >8=severe
BISAP – simple, can be done early
BUN, AMS, SIRS, Age>60, pleural effusion
>3 points indicates increased risk of death
Ranson’s criteria

15. Ranson’s Criteria At admission At 48 hrs out Age > 55 WBC > 16
Glu > 200
AST > 250
LDH > 350
Ca < 8
HCT fall > 10%
PO2 < 60
BUN increase > 5
Base deficit > 4 mEq/L
Sequestration of fluids > 6L
Criteria Met
Mortality
0-2 2%
3-4
15%
5-6
40%
7-8
100%

16. Complications
Pancreatic necrosis – becomes infected in about 30%; usually monomicrobial (Ecoli, Pseudomonas, Kleb)
Abscesses
Pseudocysts
-Drainage prior to maturation (6 wks) can lead to complications
Splenic vein thrombosis (up to 19% of pts)
Anticoagulation may be needed for complications
Abdominal compartment syndrome
ARDS, shock, renal failure, GI bleeding

17. Definitions of Pancreatic and Peripancreatic Fluid Collections
APFC: Acute Peripancreatic Fluid Collection
Assoc w intersitial panc; no necrosis
Homogenous; no definable wall; adjac to pancreas
Pancreatic Pseudocyst
Well circumscribed, homogenous, with wall
Maturation usually >4 weeks after acute panc
ANC: Acute Necrotic Collection
Only in setting of necrotizing panc
Heterogenous, no wall, intra and/or extra pancreatic
WON: Walled Off Necrosis
Heterogenous, well defined wall, intra/extra
Maturation >4 weeks after acute necrotizing panc

18. Gallstone pancreatitis – early ERCP or surgery?
Early ERCP or surgery to remove bile duct stones may decrease severity of pancreatitis
ERCP within 72 hours in pts with cholangitis OR concern for stone (stone on imaging, dilated CBD, jaundice, rising LFTs)
All patients with gallstone panc should have cholecystectomy
25-30% risk of recurrent panc, cholecystitis or cholangitis in <18 wks
Recent retrospective of mild gallstone panc who had lap chole within 48 hrs of admission
No increase in morbidity or mortality
Decreased hospital stay and ERCP
Consider early consult in appropriate patients

19. References
Banks P et al. Practice Guidelines in Acute Pancreatitis. Am J Gastroenterol 2006; 101:
Banks P et al. Classification of acute pancreatitis-2012:revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:
Al-Omran M et al. Enteral versus Parenteral Nutrition for Acute Pancreatitis (Review). Cochrane Database of Systematic Reviews 2010, Issue1
Falor et al. Early Laparoscopic Cholecystectomy for Mild Gallstone Pancreatitis. Arch Surg 147: Nov 2012
Van Santvoort et al. Early Endoscopic Retrograde Cholangiopancreatography in Predicted Severe Acute Biliary Pancreatitis: A Prospective Multicenter Study. Annals of Surgery (1); July 2009
Wu, Bechien. Prognosis in Acute Pancreatitis. CMAJ: 183 (6); April 2011