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Acute Pancreatitis

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Acute Pancreatitis By Hans Rosenberg

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Objectives Definition Etiology Clinical Presentation Diagnosis Prognosis Treatment

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Acute Pancreatitis reversible inflammatory process of the pancreas usually associated with severe acute upper abdominal pain and elevated blood levels of pancreatic enzymes pancreatic tissue or peripancreatic tissues and distant organs mild to severe Definition

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Etiology Incidence: 4.8-24.2 per 100,000 Mortality in hospitalized patients: 10% (2-22%), severe acute pancreatitis 30% Mortality in first two weeks usually due to SIRS and organ failure, > two weeks due to sepsis

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Etiology Idiopathic (30%) /Infection Gallstones (35%) Ethanol (10%) Trauma/Tumor Steroids Mumps Autoimmune – eg. SLE Scorpion Bites Hypertriglycideremia/Hypercalcemia/Hyperparathyroid Drugs – eg. diuretics Other: Pancreatic Divisum Sphincter of Oddi Dysfunction Congenital Anomalies Hypothermia Vasculitis CF

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Clinical Presentation Symptoms Acute onset persistent upper abdominal pain Nausea and vomiting +/- radiate to back, chest, flanks Appears restless Bent forward provides relief If severe: ++distress

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Signs Fever Hypotension/tachycardia Severe Abdominal Tenderness Peritoneal Signs Abdominal Distension Respiratory Distress Cullen’s, Grey-Turner’s, Fox’s Sign If severe: marked tenderness, guarding, distension, signs of hypotension shock, jaundice, respiratory findings Clinical Presentation

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Diagnosis No single test, but clinical picture and labs Lipase (> Sens and >Spec) Amylase CBC BUN/Cr LFT’s – ALT >150 IU/L high Spec for Stones Ca2+ Profile Triglycerides (acute or post-resolution) Urinalysis ABG *Bold must be done with first episode for etiology*

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CT w/ Contrast – standard technique, used in ALL with unclear diagnosis or in severe disease (as per APACHE II) at 72hrs Endoscopic Retrograde Cholangiopancreatography (ERCP) Trans-abdominal U/S – 1st episode, etiology Chest/Abdo XR Magnetic Resonance Cholangiopancreatography (MRCP) Endoscopic Ultrasonography Diagnosis

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Prognosis Goal to differentiate/stratify ? mild/moderate/severe disease Acute Physiology and Chronic Health Evaluation (APACHE II) Computed Tomography Severity Index – most accurate predicting severity of Acute Pancreatitis Ranson’s Criteria

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Prognosis APACHE II scale includes the following factors: age, rectal temperature, mean arterial pressure, heart rate, PaO2, arterial pH, serum potassium, serum sodium, serum creatinine, hematocrit, white blood cell count, Glasgow Coma Scale score, chronic health status Scoring: Can be calculated at http://www.sfar.org/scores2/apache22.html#calcul Severe if >8

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Scoring: CT grade + Necrosis CT Grade A = normal pancreas (0) B = edematous pancreas (1) C = B + mild extrapancreatic changes (2) D = severe extrapancreatic changes and 1 fluid collection (3) E = multiple or extensive fluid collections (4) Computed Tomography Severity Index

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Necrosis Score None (0) <1/3 (2) >1/3 but <1/2 (4) >1/2 (6) Computed Tomography Severity Index

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CT Severity Index score >5 correlated with prolonged hospitalization and higher rates of mortality and morbidity. CT Severity Index score >5 associated with a mortality rate 15 times higher than in those with a score of less than 5 Computed Tomography Severity Index

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Contrast-enhanced axial computed tomographic section of the upper abdomen showing peripancreatic and retroperitoneal edema. Large non-enhancing areas of necrosis are visible in the body and neck of the pancreas (arrows)

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Ranson’s Criteria Mild if <3, Severe if >3 with one point for each of below At admission or diagnosis: Age > 55 yo WBC > 16 x10e9/L BS > 11.1 mmol/L Serum LDH > 350 U/L AST > 250 U/L During initial 48hrs: BUN > 1.8 mmol/L Serum Ca2+ < 2 mmol/L Hematocrit Decrease > 10% Base Deficit > 4 meq/L Fluid Sequestration > 6 L PaO2 < 60 mm Hg

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Treatment Volume Repletion – eg. D5W 1L/hr until U/O >0.5-1cc/kg/hr Analgesia – eg. Morphine 5-10mg IV prn, Gravol 50mg IV prn Monitoring Hemodynamics and Volume NG tube if vomiting Nutrition: Total Enteral Nutrition > Parenteral Nutrition Begin once pain improves and labs normalize Enteric Options include: oral, nasgastric and nasojejunal

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If severe consider: ICU, Surgical Debridement for infected necrosis, no oral intake first 48hr, emergent ERCP if gallstones/obstructive etiology suspected, Antibiotic Prophylaxis if suspected infection - gram neg and anaerobes, fine needle aspiration to guide therapy Admission Algorithm at Ottawa Hospital Obstructive Etiology ? General Surgery Other Etiology ? CTU/Family Medicine Treatment

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Questions?? ???????

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References Acute Pancreatitis: Diagnosis, Prognosis, and Treatment. JENNIFER K. CARROLL et al. American Family Physician May 15, 2007 Vol. 75 No. 10 Diagnosis and management of acute pancreatitis. Munoz A, Katerndahl DA. Am Fam Physician. 2000 Jul 1;62(1):164-74. UpToDate

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If severe consider: ICU, Surgical Debridement for infected necrosis, no oral intake first 48hr, eme more If severe consider: ICU, Surgical Debridement for infected necrosis, no oral intake first 48hr, emergent ERCP if gallstones/obstructive etiology suspected, ... less