40 ACUTE PANCREATITIS
Clay Cothren M.D., Jon M. Burch M.D.

1. What are the common causes of acute pancreatitis?

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Gallstones (45%), alcohol (35%), and other (20%).

2. What are the uncommon causes?

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Hyperlipidemia, hypercalcemia (hyperparathyroidism, multiple myeloma), iatrogenic factors (endoscopic retrograde cholangiopancreatography), drugs (didanosine, thiazide diuretics, H2 blockers, tetracycline, azathioprine), infections (mumps, coxsackievirus), pancreas divisum, and scorpion bites (favorite pimp question on rounds). Approximately 10% of cases are considered truly idiopathic.

3. What are the characteristic symptoms?

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Acute onset of severe epigastric pain that is boring in nature and often radiates to the back. Pain frequently is accompanied by nausea and vomiting.

4. What may be found on physical examination?

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Diffuse abdominal tenderness, abdominal distention, a “board-like” abdominal guarding, and hypoactive bowel sounds. Patients may be febrile, tachycardic, and dehydrated. Evidence of jaundice or identification of gallstones on right upper quadrant ultrasound is associated with a biliary cause of pancreatitis.

5. What is the appropriate therapy for mild to moderate pancreatitis?

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The critical component of supportive therapy is fluid resuscitation to maintain urine output (place a Foley catheter). Nasogastric decompression in the presence of vomiting, pain medications, alcohol withdrawal prophylaxis, and avoidance of oral feeding until the patient clinically improves should also be done.

6. Which is the better laboratory test, amylase or lipase?

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Serum lipase has somewhat greater sensitivity and specificity; however, an isolated elevation of lipase with a normal amylase is unlikely to be caused by pancreatitis. Serum amylase levels tend to peak sooner than lipase levels, which may remain elevated for 4-5 days. Up to 30% of patients with pancreatitis have normal amylase levels, most notably alcoholics with chronic “burned-out” pancreatitis. The absolute levels do not correlate with severity of disease, although an amylase level > 500 most likely derives from the pancreas.

7. What other disease states cause hyperamylasemia?

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Perforated peptic ulcers, small bowel obstruction, parotid inflammation or tumor, and ovarian tumors are associated with elevated amylase levels.

8. What are Ranson’s indices (criteria)?

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Ranson’s indices are 11 measurements that are useful in predicting the occurrence (and severity) of pancreatitis.

9. How do Ranson’s indices relate to mortality?

Number of criteria Mortality rate (%)
0-2 5
3-4 15
5-6 50
7-8 100

KEY POINTS: ACUTE PANCREATITIS

1. Causes: gallstones (45%), alcohol (35%), other (10%), idiopathic (10%).
2. Symptoms: acute onset of epigastric pain that radiates to back with associated nausea and/or emesis.
3. Lab tests: elevated amylase and/or lipase (more sensitive).
4. CT can be diagnostic, especially in severe cases.
5. Management is supportive; 10% of cases progress to hemorrhagic or necrotizing pancreatitis.

10. What is necrotizing pancreatitis?

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The inflammation and edema of acute pancreatitis may progress with subsequent devitalization of pancreatic and peripancreatic tissue. Pancreatic necrosis occurs in approximately 20% of acute episodes.

11. Why is it important to differentiate acute pancreatitis from necrotizing pancreatitis?

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The presence and extent of necrosis are key determinants of the clinical course. Approximately 70% of patients with pancreatic necrosis develop infected pancreatic necrosis; infection accounts for 80% of all deaths from pancreatitis and is an absolute indication for surgery.

12. What is the optimal method for diagnosing pancreatic necrosis with or without associated infection?

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Dynamic computed tomography (CT) scans with contrast allow visualization and differentiation of healthy perfused parenchyma from patchy, poorly perfused necrotic tissue. CT-guided aspirate of the necrotic tissue should be sent for Gram stain and culture to determine the presence of infection.

13. When is surgery indicated in patients with pancreatitis?

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Infected pancreatic necrosis is the only absolute indication for surgery. Open drainage is best accomplished via a bilateral subcostal incision, placement of the greater omentum over the transverse colon to prevent enteric fistulas, and removal of necrotic material from the lesser sac. The patient may require multiple trips to the operating room for repeated debridement; the abdomen is not formally closed until only viable tissue remains.

14. When should antibiotic therapy be added?

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Patients with mild cases of pancreatitis should be treated with supportive measures because antibiotics do not alter the course or septic complications of the disease. In cases of necrotizing pancreatitis, randomized trials have shown a decreased incidence of sepsis in patients treated with the broad-spectrum antibiotic imipinem. Patients who have more than three Ranson’s criteria or are at high risk should be considered for early antibiotic treatment.

15. What is the most common complication of acute pancreatitis?

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Patients who develop pancreatic pseudocysts typically present with persistent abdominal pain, nausea and vomiting, and an abdominal mass. One should wait 6-12 weeks for the pseudocyst to “mature” before undertaking operative or endoscopic drainage.

16. What is the significance of hypoxemia early in the course of pancreatitis?

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Patients with necrotizing pancreatitis may develop respiratory failure requiring mechanical ventilation. In addition, they may become hemodynamically unstable and progress to multiple organ failure. Hypoxemia is an ominous sign.
17. What is the natural history of gallstone pancreatitis? Show answer
Attacks recur. Cholecystectomy is curative and is performed before patient discharge.

18. What is the natural history of alcoholic pancreatitis?

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Attacks recur. Abstinence from alcohol should be encouraged because many patients develop chronic pancreatitis.

References
WEB SITE
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