Acute Pancreatitis - Diagnosis and Management - GrepMed Handbook



Presentation: 

 • Epigastric abdominal pain (90%, characteristically radiating to back), N/V (90%)

 • Other: Jaundice (obstruction), Periumbilical (Cullen) or flank (Grey-Turner) bruising in severe hemorrhagic.



Etiology: 

 • Gallstones (40-50%), EtOH (30%), Hypertriglyceridemia 10%), HyperCa2+

 • Other: ERCP/surgery, Trauma, Drugs, Autoimmune, PUD (posterior), Anatomic (divisum/annular pancreas, sphincter dysfunction), Familial, Infectious, Ischemia, Cancer/Mets, Radiation, Cystic Fibrosis



Diagnosis (2 of 3):

1) Characteristic presentation   

2) Lipase > 3x ULN   

3) Imaging findings

Workup:

 • Labs: Lipase, Ca2+, LFTs, Triglycerides (>1000 mg/dL)

 • Imaging: US (biliary evaluation, gallstones), CT (early only to clarify diagnosis, can be normal early; late to assess for complications), MRCP (necrosis, biliary, stones), CTA if suspect hemorrhage



Management:

 • IVF - Moderate fluid resuscitation in first 24h

 • Analgesia: Scheduled APAP, IV Opioids (can worsen ileus), consider pain-dose ketamine (ICU); consider epidural if available.

 • Nutrition: Early enteral improves outcomes, consider NGT if unable to tolerate within 48-72h. Can immediately start with low-fat (as safe as CLD). Avoid TPN.

 • Antibiotics: AVOID

 • Gallstones: Urgent ERCP (w/in 24h) if cholangitis, consider ERCP + cholecystectomy during hospitalization

 • HyperTrig: D10+insulin gtt (goal TG < 500-1000, closely monitor electrolytes), gemfibrozil 600 bid

 • HyperCa2+: Bisphosphonates, calcitonin

 • Infected Necrosis - Dx: FNA if suspected. Tx: ABx (pip-tazo, carbapenem or cefepime+flagyl) ± drainage.



Check out https://emcrit.org/ibcc/pancreatitis/ for a definitive guide to diagnosis and management of pancreatitis (and discussion of fluid management)



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