ACUTE PANCREATITIS

Tim Pieh, MD
Maine-Dartmouth Family Practice Residency
 OUTLINE

• Diagnosis
• Etiology
• Assessing severity
• Treatment
• Complications
 CASE
• 64 yo woman develops upper abd pain
late last night. Band-like with radiation to
back. Initially not severe, but awoke and
had several episodes of non-bloody
emesis. No F/C, no dark urine

• The first 8 hours in ED/Hospital needs 36

mg MSO4 to control pain.
 CASE
• PMHx: HTN, • BP: 94/45  160/90,
Hyperlipidemia HR: 76, T: 97.9,
• PSurgHx: TAH-BSO • GEN: awake alert
• MEDS: Estrace, • HEENT: no icterus,
Plendil mouth is dry
• SOCIAL: no tobacco • CARDIO: RRR
or ETOH • ABD: SNT, no
rebound, no bruising
 CASE
• ABD CT: marked • LABS:
peripancreatic fluid, • AST/ALT both slightly
streaking around elevated.
pancreas, normal • T.bili normal
enhancement, no
• Amylase 2620
clear gallstones, CBD
not dilated • lipase 26,625
• Hct normal
• WBC 14.8
 MORTALITY

• Mild Acute Pancreatitis

– < 5%
• Severe Acute Pancreatitis
– 25%

• Nearly 20% of all pts with AP develop SAP

• 25% of SAP pts die
 DISEASE COURSE
– Deaths occur in 2 phases:
– PHASE 1 (with in first few days):
• SIRS
• ARDS
– PHASE 2 (after second week):
• Sterile necrosis
• Infected necrosis
• Multiple organ dysfunction
 DIAGNOSIS
• FAIRLY SUDDEN ONSET UPPER ABD PAIN
• RADIATION TO BACK
• N/V

• ELEVATED AMYLASE
• ELEVATED LIPASE
• CULLEN SIGN (PERIUMBILICAL BRUISING)
• GREY-TURNER SIGN (FLANK BRUISING)
 CAUSES
• The Big Three:

– Gall Stones (40%)

– Alcohol (35%)
– Idiopathic (20%)
 CAUSES
• The Others:
– Trauma (pancreatic duct injury)
– Post-ERCP
– Drugs (rare)
• 30 meds identified
– Azathioprine (Imuran – immune suppressant)
– Valproic acid (Depakote – seizures/mood stabilizer)
– Didanosine (Videx – HIV med)
– Pentamidine (HIV – pneumocystis carinii Tx)
– Mesalamine (Asacol – ulcerative colitis Tx)
 CAUSES
– Organ transplant, major surgery
– Hypertryglycerides (rare)
• Greater than 1000 mg/dL
– Pregnancy
• Third trimester until 6 weeks post partum
– HIV
• 35 to 800 times greater risk of AP c/w general pop.
– Hypercalcemia
• Most often secondary to hyperparathyroidism
– Scorpion, spider, and Gila Monster lizard bites
 PREDICTING CAUSES

– Gallstones:
• ALT > 150 IU/dL  PPV >95%
• Ultrasound will see gallstones in 60-80% of cases
• (Less reliable for stones in CBD)
• MRCP sensitivity 90-100%

– ETOH
• Lipase > amylase
 SEVERITY

• Early identification of severity and

appropriate ICU care has significantly
reduced mortality over the last 20 yrs

• Bedside eval (compared to severity

scoring) missed over 50% of severe cases
 SEVERITY
• When do you do “early” transfer to ICU?
• When do you consult critical care team?
• When do you start antibiotics?
• When do you get a CT scan?
• “They” say people crash fast – who are
these people?
• What is “aggressive fluid resuscitation?”
 SEVERITY
• APACHE II
– Best test
• Can be done at 24 hrs, can be repeated
• Ranson’s Criteria (1974!)
• Needs to be done at 24 and 48 hrs
• Balthazar’s (CT scan criteria)
• Glascow
• Single Markers of Severity
 APACHE II

http://www.sfar.org/scores2/apache22.html

≥ 8 is severe
Ranson’s Criteria
≥ 3 is severe
SINGLE MARKER’S
 CASE
• At 36 hrs you are night float and get a call
from RN. Pt with increased work at
breathing, crackles at bases of lungs. She
is 4 liters ahead on fluids.

• What do you want to do?

 TREATMENT
• “Vigorous intravenous hydration alone is
the best available option in the prevention
of pancreatic necrosis.”

– Pitchhumoni et al. “Mortality in Acute Pancreatitis,”

Journal of Clinical Gastroenterology
 TREATMENT
• AGGRESSIVE FLUID RESUSCITATION
– May require 250-500 cc/hr for first 48 hrs
• 6 L of fluid is sequestered in abdomen alone
• Third spacing can consume up to 1/3 of total
plasma volume
– 1/3 of people die in the first phase  50% of
these are associated to ARDS

• PULMONARY EDEMA ≠ CHF

 TREATMENT

• INFLAMMATORY MEDIATORS &

PANCREATIC SECRETIONS ARE
WASHING THROUGH THE LUNGS

• INCREASED PULM. VASCULAR

PERMEABILITY  PULMONARY
EDEMA
 TREATMENT
• How do you know you are resuscitated?
– Blood pressure
– Heart rate
– Urine output
– SPO2/ABG’s show good oxygenation and no
acidemia
 TREATMENT
• AGGRESSIVE FLUID RESSUCITATION
– You may create electrolyte imbalances that need to
be corrected
– You may need CVP monitoring (central line)
– CXRs help (CHF vs ARDS)
– ABGs help (still hypoxic  need more fluids?)

– 23% of SAP pts get ARF  80% mortality

– 0.5 cc/kg/hr urine output is goal (need a Foley)

 TREATMENT
• OXYGENATE
– Give O2 (spO2≥95%)
– Liberal intubation/ventilation to treat ARDS

• SCDs
 NECROSIS
• Starts to occur within 4 days of disease
• CT with po & IV contrast is gold standard
– Necrotic areas do not enhance
– You will NOT see it on CT before 48hrs
• Once you Dx necrosis mortality jumps
– 40-60% get secondary infection
– Mortality then approaches 80%
 SECONDARY INFECTIONS
• SYMPTOMS:
– N/V, epigastric pain, distension, fever,
elevated WBC
• Diagnosis of sterile vs infected necrosis
– CT-guided needle aspiration
• This is the most devastating complication
and marks the second peak in mortality
(@ 2 weeks)
 SECONDARY INFECTIONS
• FLUID COLLECTIONS
• PSEUDOCYSTS
• PANCREATIC NECROSIS

• Above get infected in 1-10% of all acute

pancreatitis, but are source of 80% of
deaths
 SECONDARY INFECTIONS
• What bugs?
• Gram (-) bacteria cross from gut
– E. coli (35%)
– Klebsiella (24%)
– Enterococcus (24%)
– Staph (14%)
– Pseudomonas, proteus, strep, enterobacter,
bacteroides, anaerobes
 SECONDARY INFECTIONS

• Pathogens colonize gut

• Intestinal mucosal barrier breaks down
• Bacteria crosses through
 ANTIOBIOTICS
• Controversial
• They DO decrease incidence of infection
in necrosis, but do NOT decrease mortality
• Gotta cover multiple bugs
• Gotta get into pancreas

• If you see necrosis  start antibiotics (?)

 ANTIOBIOTICS
• Imipenem

• Cipro + metronidazole

• One study showed 24% of pts had fungus

– Very poor prognosis
 NUTRITION
• Normal pancreas secretes up to 2
liters/day of secretions
• Pancreatic stimulation during AP releases
proteolytic enzymes  autodigestion
• Oral feeding increases release of secretin
and cholecystokinin  stim pancreas
• “rest the pancreas”  “NPO”
 NUTRITION
• TRADITION:

– Rest the pancreas  NPO

– TPN only after 5-7 days (prevent starvation)
– Ill pts can’t be fed (ileus, aspiration)
 NUTRITION
• ENTERAL vs TPN Feedings:
– If distal to Ligament of Treitz (nasojejunal tube
or J-tube) pancreatic secretion = basal rate
– Both started after 48 hours
• Easier to restart po feedings
• Average length of nutritional support shorter
– 7 vs 11 days
• Fewer septic complications
• $23/day vs $222/day
 NUTRITION
• NEW THOUGHTS
– Meta-analysis of 15 randomized studies:
• Compared early vs delayed ENTERAL feedings in
753 critically ill pts
• Early was 36 hrs!
• Improved:
– Wound healing
– Host immune function
– Preservation of intestinal mucosal integrity
– Decreased infections
• BUT, no decreased mortality
 NUTRITION

• Feed to maintain gut integrity

• Protects against transfer of bacteria

 ERCP

• If there is a stone or cholangitis (biliary

sepsis) or persistent jaundice
• Need urgent ERCP with sphincterotomy
and stone extraction

• Otherwise, ERCP not indicated

 SURGERY
• Used to be very liberal with early surgery
• Trauma
– If duct damaged
• Gallstone etiology and mild
– Cholecystectomy in same admission
– If no chole  25-69% recurrence rate of
pancreatitis within 6-18 wks
• Sterile necrosis  controversial
• Infected necrosis  yes, but delay
 CASE REVISITED
• By 48 hours pt’s abd pain is worsening
• HR is 140, afebrile, BP normal
• Abd shows very subtle guarding
• WBC: 27.6
• Ca++: 6.6
• PO2: 61
• Base deficit: 8
• BUN rise: 9
• LDH: 976
• RANSON SCORE: 3
• APACHE II SCORE: 8
 CASE REVISITED
• Pt transferred to ICU
• Central line
• Arterial line
• Repeat Abd CT: new bilateral pleural
effusions, pancreas enhances in tail only.

• Transferred to Maine Medical Center.

• Pt died 5 weeks after admission.
 SUMMARY
• They may look good, but…
• Score severity early
• Use lots of IVF
• Go to ICU early
• Early enteral feedings work better
 REFERENCES
1. Swaroop VS. Severe Acute Pancreatitis. JAMA.2004; 291: 2865-2868.
2. Pitchumoni CS. Factors influencing mortality in acute pancreatitis. Can we alter them? J Clin
Gastroenerol. 2005; 39: 798-814
3. Mitchell RMS. Pancreatitis. Lancet. 2003; 361: 1447-1445
4. Nathens AB. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med.
2004; 32: 2524-2536.
5. Bentrem DJ. Pancreas: healing response in critical illness. Crit Care Med. 2003; 31: S582-S589
6. Bank S. Evaluation of factors that have reduced mortality from acute pancreatitis over the past 20
years. J Clin Gastroenterol. 2002; 35: 50-60
7. Werner J. Management of acute pancreatitis: from surgery to conventional intensive care. Gut.
2003: 54; 426-436.
8. Pastor CM. Pancreatitis-associated acute lung injury: new insights. Chest. 2003; 124: 2341-2351.
9. Yousef M. Management of severe acute pancreatitis. British Journal of Surgery. 2003; 90: 407-
420
10. Chari ST. Clinical manesfestations and diagnosis of acute pancreatitis. UpToDate. 2005.
11. Chari ST. Etiology of acute pancreatitis. UpToDate. 2005.
12. Chari ST. Predicting the severity of acute pancreatitis. UpToDate. 2005.