Management of Acute Pancreatitis

Fahad A Saadi
FY2 General Suregry
Altnagelvin Area Hospital
Western Trust
fsaadi01@qub.ac.uk
 Outline

• Definition

• Classification, severity and criteria for HDU

• Investigations

• Management

• Complications

• Follow-up
 Definition

Definition 2 out of 3 of the following criteria:

1) Clinical: Upper abdominal pain

2) 2) Laboratory: Serum amylase > 3 times of upper

normal limit

3) 3) Imaging: Imaging proven (CT/MRI/USS)

 History & Examination
• Previous pancreatitis

• History of gallstones

• Alcohol history

• Medication and drug intake

• Hyperlipidaemia

• Trauma Re

• cent intervention (eg. ERCP)

• Co‐morbidities (respiratory, cardiac, diabetes, high BMI)

• Family history
 Investigations

• a) FBC, U+Es, LFTs, amylase, CRP, clotting,

calcium and triglycerides +/‐ blood cultures.

• b) Arterial blood gas (to assess hypoxia or

metabolic acidosis)

• c) Chest X‐Ray (assess for effusion or ARDS)

• d) Upper abdominal ultrasound (assess aetiology)

 Immediate Management

• ABCDE

• FLUIDS:

• ‐ Hartmann’s solution

• ‐ Administer 30ml/kg for hypotension or lactate≥4mmol/l

• ‐ 5‐10mls/kg/h first 24 hours until goals met

• ‐ Goals to meet :

• Heart rate <120 /min,

• Mean arterial pressure = 65‐85mmHg,

• Urine output = 0.5‐1ml/kg/h

 Severity Grading - Atlanta

• Severe: Persistent (>48 hrs) SIRS/organ failure, local

complications or exacerbation of coexistent disease

• Moderately severe: transient SIRS (<48 hrs)

• Mild: No organ failure, local complications or

exacerbation of coexistent disease

• Assess at admission, 24 hours and 48 hours.

 Consideration of HDU

• ‐Persistent SIRS >48h

• ‐Elderly (aged >70yrs)

• ‐Obese (BMI>35)

• ‐Moderately severe pancreatitis

Urgent Senior Surgical/HDU Review
1. Clinical signs:

a. Resp. rate >35/min, HR150/min, Systolic

BP<80, Diastolic BP >120, MAP <60, Anuria

2. Bloods:

a. PH <7.1 or >7.7

b. Na <110 0r 170mmol/l

c. K <2 or >7mmol/l

d. Ca >3.75mmol/l

e. Glucose >44.4mmol/l
 Antibiotic Therapy

NOT routinely, except in these circumstances:

1. Extra‐pancreatic infection (e.g. UTI etc.)

2. Suspected cholangitis

3. USS proven cholecystitis

4. Suspected INFECTED pancreatic necrosis

 Imaging

USS abdomen: Gold standard first line

CT indications: (Optimal timing > 72‐96 hrs after onset)

a. Diagnostic uncertainty,

b. Failure to respond to initial treatment

c. Clinical deterioration

MRCP: Abnormal LFTs and CBD dilatation (when

worsen or fail to settle)
ERCP and PTC for biliary drainage

• Inpatient biliary drainage should be considered for:

a. Severe gallstone pancreatitis with cholangitis

(URGENT <24hrs)

b. Gallstone pancreatitis with obstructing AND

non‐obstructing CBD stone (where surgical bile duct
exploration inappropriate)
Necrotising Pancreatitis: Intervention

• Image‐guided percutaneous drainage: first line

• If above treatment failure:

• Surgical necrosectomy

• Discuss HPB team

 Idiopathic pancreatitis

a) Repeat abdominal USS (at 6 weeks)

b) If no gallstones then for IgG4 – to exclude

autoimmune pancreatitis

c) If above normal then for MRCP

d) If above normal then for endoluminal ultrasound

(EUS)
 Alcohol‐related pancreatitis

• For acute alcohol‐related pancreatitis: tx as usual

• For chronic alcohol‐related pancreatitis diagnosis requires:

a. symptoms

b. CT scan first line determine pancreatic structure

c. Tests of pancreatic exocrine and endocrine function

a. Consider: pancreatic enzyme supplements, surgery,

coeliac plexus block, splanchnicectomy
 Conslusion

1. Hyponatraemia Na < 130 mmol/L

2. Determine serum osmolality

• True hyponatraemia is: Hypoosmolar Hypovolaemic

3. Determine Volume status (Hypo-, Hyper-, Euvolaemic)

4. Determine urine sodium to differentiate Hypo-, Hyper-,

Euvolaemic hyponatraemia

5. Treat based on aetiology and acuteness of development

 References

1. Working group IAP/APA acute pancreatitis guidelines.

IAP/APA evidence‐based guidelines for the management
of acute pancreatitis. Pancreatology 2013; 13:e1‐e15.

2. UK working party on acute pancreatitis. UK guidelines

for the management of acute pancreatitis. Gut 2005;
54:1‐9.

3. NICE. Alcohol‐related pancreatitis. NICE pathways

2015.
http://pathways.nice.org.uk/pathways/alcohol‐use‐disorder
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 Questions

Thank you!