Acute Pancreatitis

Acute pancreatitis is an inflammatory disease of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas due to autodigestion. Common etiologies include gallstones and excessive alcohol use. Patients typically present with epigastric pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain radiating to the back. Diagnosis requires 2 of 3 criteria, including: characteristic abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, serum amylase and lipase 3 times the upper limit of normal, or characteristic radiology findings. Ranson’s criteria is commonly used to assess the severity. Management includes aggressive intravenous (IV) hydration, analgesia, nutritional support, and treatment of the underlying cause.

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Epidemiology and Etiology

Epidemiology

  • Incidence:
    • United States: 40–50 cases per 100,000 adults
    • Worldwide: 5–80 per 100,000 adults
  • Men > women
    • Men: likely due to alcohol
    • Women: related to biliary tract Biliary tract Bile is secreted by hepatocytes into thin channels called canaliculi. These canaliculi lead into slightly larger interlobular bile ductules, which are part of the portal triads at the "corners" of hepatic lobules. The bile leaves the liver via the right and left hepatic ducts, which join together to form the common hepatic duct. Gallbladder and Biliary Tract disease
  • Mortality is approximately 5%, overall:
    • Necrotizing pancreatitis: 17%
    • Interstitial pancreatitis: 3%

Etiology

  • Biliary tract disease: 
    • Approximately 40% of cases
    • Caused by biliary obstruction due to a stone
  • Alcohol use:
    • Approximately 30% of cases
    • Often an exacerbation of chronic pancreatitis Chronic pancreatitis Chronic pancreatitis is due to persistent inflammation, fibrosis, and irreversible cell damage to the pancreas, resulting in a loss of endocrine and exocrine gland function. The most common etiologies are alcohol abuse and pancreatic duct obstruction. Patients often present with recurrent epigastric abdominal pain, nausea, and features of malabsorption syndrome (diarrhea, steatorrhea, and weight loss). Chronic Pancreatitis
    • Usually seen with habitual consumption over 515 years, but may be seen after a binge
  • Endoscopic retrograde cholangiopancreatography (ERCP):
    • Can cause accidental lodging of stone into the sphincter of Oddi
    • Increased risk in sphincter of Oddi dysfunction
  • Abdominal trauma:
    • More often in penetrating injuries
    • Blunt trauma may lead to ductal injury
  • Drugs:
    • Azathioprine
    • Sulfonamides
    • Tetracycline
    • Valproic acid
    • Estrogens
    • Thiazide and loop diuretics Loop diuretics Loop diuretics are a group of diuretic medications primarily used to treat fluid overload in edematous conditions such as heart failure and cirrhosis. Loop diuretics also treat hypertension, but not as a 1st-line agent. Loop Diuretics
    • Corticosteroids
    • Octreotide
    • Pentamidine
  • Idiopathic: 
    • Approximately 10%–30% of cases
    • Occult microlithiasis may be responsible.
  • Less common causes:
    • Infections: 
      • Mumps Mumps Mumps is caused by a single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae. Mumps is typically a disease of childhood, which manifests initially with fever, muscle pain, headache, poor appetite, and a general feeling of malaise, and is classically followed by parotitis. Mumps Virus/Mumps
      • Hepatitis
      • Cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus
      • Coxsackievirus Coxsackievirus Coxsackievirus is a member of a family of viruses called Picornaviridae and the genus Enterovirus. Coxsackieviruses are single-stranded, positive-sense RNA viruses, and are divided into coxsackie group A and B viruses. Both groups of viruses cause upper respiratory infections, rashes, aseptic meningitis, or encephalitis. Coxsackievirus
      • Salmonella Salmonella Salmonellae are gram-negative bacilli of the family Enterobacteriaceae. Salmonellae are flagellated, non-lactose-fermenting, and hydrogen sulfide-producing microbes. Salmonella enterica, the most common disease-causing species in humans, is further classified based on serotype as typhoidal (S. typhi and paratyphi) and nontyphoidal (S. enteritidis and typhimurium). Salmonella
      • Parasites
    • Genetic predispositions (e.g., CFTR mutation Mutation Genetic mutations are errors in DNA that can cause protein misfolding and dysfunction. There are various types of mutations, including chromosomal, point, frameshift, and expansion mutations. Types of Mutations, as in cystic fibrosis Cystic fibrosis Cystic fibrosis is an autosomal recessive disorder caused by mutations in the gene CFTR. The mutations lead to dysfunction of chloride channels, which results in hyperviscous mucus and the accumulation of secretions. Common presentations include chronic respiratory infections, failure to thrive, and pancreatic insufficiency. Cystic Fibrosis)
    • Hypercalcemia Hypercalcemia Hypercalcemia (serum calcium > 10.5 mg/dL) can result from various conditions, the majority of which are due to hyperparathyroidism and malignancy. Other causes include disorders leading to vitamin D elevation, granulomatous diseases, and the use of certain pharmacological agents. Symptoms vary depending on calcium levels and the onset of hypercalcemia. Hypercalcemia
    • Hypertriglyceridemia
    • Tumors
    • Toxins: 
      • Organophosphates 
      • Scorpion bite
    • Vascular or ischemic
    • Autoimmune pancreatitis (IgG4)
    • Developmental:
      • Pancreatic ductus divisum: failure of the dorsal and ventral pancreatic ducts to fuse
      • Annular pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas: a band of pancreatic tissue surrounds the 2nd part of the duodenum
      • Sphincter of Oddi dysfunction

Related videos

Pathophysiology

Normal pancreatic function

  • The pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas has endocrine ( insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin) and exocrine (digestive enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes) functions.
  • Digestive enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes made in acinar cells → stored as zymogens (inactive form) → released in the pancreatic duct and small intestine Small intestine The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine → activation by trypsin
  • Protective mechanisms against organ injury (autodigestion) include:
    • Negative feedback mechanism (↑ trypsin in duodenum → ↓ cholecystokinin (CCK) and secretin → ↓ pancreatic secretion)
    • Zymogens are controlled with protease inhibitors.
    • ↓ Acinar cell pH and calcium concentrations → prevent premature activation of trypsin
  • Anything that disrupts the homeostasis of normal pancreatic function can cause acute pancreatitis.

Acute pancreatitis pathogenesis

  1. Initiated through acinar cell injury Cell injury The cell undergoes a variety of changes in response to injury, which may or may not lead to cell death. Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Cell Injury and Death from:
    • Biliary obstruction → increased pancreatic duct pressure → acinar cell injury Cell injury The cell undergoes a variety of changes in response to injury, which may or may not lead to cell death. Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Cell Injury and Death
    • Direct injury (e.g., toxins, alcohol)
  2. Changes in acinar cell pH and calcium concentrations → allows intrapancreatic activation of trypsin → activation of zymogens → autodigestion
  3. Inhibited secretion on zymogens into the pancreatic ducts → exocytosis into the interstitium → not fully understood, but believed to lead to attraction of inflammatory cells
  4. Inflammatory cells arrive → cytokine release → pancreatic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  5. Cytokine release and vascular injury from enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes → vasodilation and vascular permeability → fluid shifting to the interstitial space (3rd spacing) → decreased perfusion and hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension → can result in:
    • Shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock
    • Acute renal failure
    • Pancreatic necrosis
Pathogenesis acute pancreatitis

Acute pancreatitis

Image by Lecturio.

Clinical Presentation

Symptoms

  • Acute abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Epigastric
    • Dull and steady
    • Sudden onset, increasing in severity
    • Radiation to the back (approximately 50% of patients)
  • Nausea and vomiting
  • Anorexia
  • Diarrhea
  • Low-grade fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever

Physical examination

  • General:
    • Tachycardia
    • Abdominal tenderness
    • Abdominal distention
    • Diminished bowel sounds → ileus
  • Evidence of severe disease:
    • Fever
    • Hypotension
    • Tachypnea and crackles
    • Pale and diaphoretic
  • Signs of an underlying cause:
    • Hepatomegaly → alcoholic pancreatitis
    • Scleral icterus or jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice → choledocholithiasis
    • Muscle spasms → hypocalcemia Hypocalcemia Hypocalcemia, a serum calcium < 8.5 mg/dL, can result from various conditions. The causes may include hypoparathyroidism, drugs, disorders leading to vitamin D deficiency, and more. Calcium levels are regulated and affected by different elements such as dietary intake, parathyroid hormone (PTH), vitamin D, pH, and albumin. Presentation can range from an asymptomatic (mild deficiency) to a life-threatening condition (acute, significant deficiency). Hypocalcemia
    • Xanthomas → hypertriglyceridemia
  • Warning signs of retroperitoneal bleeding in severe, necrotizing pancreatitis:
    • Cullen’s sign: bluish discoloration around the umbilicus due to blood in the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum and Retroperitoneum
    • Grey-Turner’s sign: reddish-brown discoloration on the flanks due to blood in the retroperitoneum or pancreatic exudates

Diagnosis

Diagnostic criteria

The diagnosis of acute pancreatitis requires at least 2 of the following:

  • Acute onset of epigastric abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Serum amylase or lipase > 3 times the upper limit of normal
  • Characteristic findings on imaging

Laboratory evaluation

  • ↑ Serum amylase
  • ↑ Serum lipase: more specific for pancreatitis
  • Hepatic function tests:
    • Alanine transaminase (ALT) > 150 U/L and ↑ bilirubin → pancreatitis secondary to gallstones
    • Maybe be ↑ with heavy alcohol use
  • Basic metabolic panel:
    • Calcium:
      • ↑ Calcium → may be a potential cause of pancreatitis
      • ↓ Calcium → frequently seen, and should be corrected
    • Electrolyte imbalances can occur due to 3rd spacing of fluids
    • ↑ Blood urea nitrogen (BUN) → severe disease
  • Lactate dehydrogenase (LDH): ↑ in severe disease
  • Complete blood count:
    • ↑ Hematocrit → severe disease
    • ↑ WBCs → inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • C-reactive protein (CRP): > 150 mg/L at 48 hours → risk of severe pancreatitis and organ failure
  • Triglycerides: ↑ in hypertriglyceridemia
  • Immunoglobulin G4 (IgG4): may be checked if autoimmune pancreatitis is suspected
  • Arterial blood gas:
    • Should be done if the patient is tachypneic
    • Can evaluate oxygenation and acid-base status
Milky plasma

Milky plasma seen in a patient with hypertriglyceridemia: If seen, milky plasma should be considered as a potential cause of acute pancreatitis.

Image: “Milky plasma” by the Department of Emergency and Critical Care Medicine, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan. License: CC BY 2.0.

Imaging

Imaging may not be required if the 1st 2 diagnostic criteria are met, but can be used for evaluating the underlying cause and complications:

  • Computed tomography (CT):
    • Normal in 30% of cases
    • Potential findings:
      • Inflammatory changes of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas
      • Necrosis, fluid collections, or pseudocysts can be seen later in the course.
  • Abdominal ultrasound (US):
    • Can be done if gallstone pancreatitis is suspected
    • Potential findings:
      • Gallstones
      • Common bile duct (CBD) dilation
      • Pancreatic edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema 
      • Peripancreatic fluid
  • Magnetic resonance cholangiopancreatogram (MRCP):
    • Can evaluate the biliary system
    • Findings:
      • Choledocholithiasis
      • Biliary dilation
      • Pancreatic edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
      • Pancreatic necrosis or pseudocysts
  • Chest radiograph:
    • For patients with pulmonary symptoms ( dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, tachypnea, hypoxia)
    • Potential findings: 
      • Pleural effusions
      • Basal atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis
      • Diffuse, patchy infiltrates indicating acute respiratory distress syndrome Acute Respiratory Distress Syndrome Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome ( ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome)
  • Abdominal radiograph:
    • Limited role
    • “Sentinel loop” finding (short segment of ileus near the pancreatic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation)

Prognosis evaluation

Identifying the severity of acute pancreatitis is helpful in order to ensure the patient is treated appropriately:

  • Ranson’s criteria (see table):
    • Widely used
    • The biggest disadvantage is that it takes 48 hours to complete the assessment.
  • Bedside index of severity in acute pancreatitis (BISAP) score (see table):
    • Simple
    • Calculated during the 1st 24 hours
  • APACHE II score:
    • Evaluates age, temperature, mean arterial pressure, heart rate, respiratory rate, blood gas results, WBC count, electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes, creatinine, Glasgow coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma score (GCS), and other health conditions
    • Very cumbersome and complex
Table: Ranson’s criteria (1 point each)
Present on admission At 48 hours after admission
Age > 55 years Decrease in hematocrit > 10%
WBC > 16,000/μL Increase in BUN by > 8 mg/dL
Blood glucose > 200 mg/dL Serum Ca < 8 mg/dL
Serum LDH > 350 IU/L PaO2 < 60 mm Hg
Aspartate transaminase (AST) > 250 IU/L Base deficit > 4 mEq/L
Estimated fluid sequestration > 6 L
0‒2: Minimal mortality
3‒5: 10%‒20% mortality rate, must be admitted to ICU
> 5: Increased risk of systemic complications and mortality

Definitions:
  • PaO2 is the partial pressure of oxygen in arterial blood.
  • Base deficit indicates excess acid in the blood.
Table: BISAP score (1 point each)
BUN > 25 mg/dL
Impaired mental status GCS < 15
Systemic inflammatory response syndrome (SIRS) Evidence of SIRS
Age > 60 years
Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion Positive finding on imaging
0‒2 points: lower mortality (< 2%)
3‒5 points: higher mortality (> 15%)

Management

Acute management

  • Basic treatment:
    • Aggressive intravenous fluid ( IVF IVF Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids) resuscitation 
    • Fluid intake and output monitoring
    • Close vital sign monitoring
    • Address electrolyte imbalances
    • Medications:
      • Analgesics (typically opioids Opioids Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid Analgesics)
      • Antiemetics Antiemetics Antiemetics are medications used to treat and/or prevent nausea and vomiting. These drugs act on different target receptors. The main classes include benzodiazepines, corticosteroids, atypical antipsychotics, cannabinoids, and antagonists of the following receptors: serotonin, dopamine, and muscarinic and neurokinin receptors. Antiemetics
    • Initial bowel rest
    • Early nutritional support:
      • Can be started as early as 24 hours, if pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain is decreasing
      • Is associated with ↓ morbidity compared to delayed or no nutrition
  • Mild acute pancreatitis:
    • Can be treated on a general medical ward
    • May begin low-residue, low-fat diet as soon as tolerated
  • Severe acute pancreatitis:
    • Intensive care setting is preferred.
    • May require enteral nutrition if the patient cannot tolerate oral intake: Start within 72 hours.

Treating the etiology

  • Gallstones
    • ERCP:
      • Can perform sphincterotomy and stone extraction
      • Indicated for choledocholithiasis or evidence of cholangitis
    • Cholecystectomy Cholecystectomy Cholecystectomy is a surgical procedure performed with the goal of resecting and extracting the gallbladder. It is one of the most common abdominal surgeries performed in the Western world. Cholecystectomy is performed for symptomatic cholelithiasis, cholecystitis, gallbladder polyps > 0.5 cm, porcelain gallbladder, choledocholithiasis and gallstone pancreatitis, and rarely, for gallbladder cancer. Cholecystectomy: Approaches and Technique:
      • Surgical removal of the gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract
      • Performed after recovery from pancreatitis
  • Hypertriglyceridemia:
    • Goal triglyceride level is < 500 mg/dL.
    • Intravenous (IV) insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin:
      • Requires close glucose monitoring
      • May need a concurrent dextrose infusion to prevent hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia 
    • Apheresis:
      • Should be considered in patients with SIRS, hypocalcemia Hypocalcemia Hypocalcemia, a serum calcium < 8.5 mg/dL, can result from various conditions. The causes may include hypoparathyroidism, drugs, disorders leading to vitamin D deficiency, and more. Calcium levels are regulated and affected by different elements such as dietary intake, parathyroid hormone (PTH), vitamin D, pH, and albumin. Presentation can range from an asymptomatic (mild deficiency) to a life-threatening condition (acute, significant deficiency). Hypocalcemia, and multi-organ dysfunction
      • May not be available at all hospitals
  • Alcohol:
    • Patient education
    • Abstinence

Complications

Infected pancreatic necrosis or abscess

  • Consider if patients continue to have a fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever or increasing leukocytosis
  • ⅓ of patients with pancreatic necrosis will develop infection.
  • Causative organisms: 
    • E. coli
    • Pseudomonas Pseudomonas Pseudomonas is a non-lactose-fermenting, gram-negative bacillus that produces pyocyanin, which gives it a characteristic blue-green color. Pseudomonas is found ubiquitously in the environment, as well as in moist reservoirs, such as hospital sinks and respiratory equipment. Pseudomonas
    • Klebsiella Klebsiella Klebsiella are encapsulated gram-negative, lactose-fermenting bacilli. They form pink colonies on MacConkey agar due to lactose fermentation. The main virulence factor is a polysaccharide capsule. Klebsiella pneumoniae is the most important pathogenic species. Klebsiella
    • Enterococcus Enterococcus Enterococcus is a genus of oval-shaped gram-positive cocci that are arranged in pairs or short chains. Distinguishing factors include optochin resistance and the presence of pyrrolidonyl arylamidase (PYR) and Lancefield D antigen. Enterococcus is part of the normal flora of the human GI tract. Enterococcus
  • Treatment:
    • Antibiotics:
      • Carbapenems 
      • Fluoroquinolones Fluoroquinolones Fluoroquinolones are a group of broad-spectrum, bactericidal antibiotics inhibiting bacterial DNA replication. Fluoroquinolones cover gram-negative, anaerobic, and atypical organisms, as well as some gram-positive and multidrug-resistant (MDR) organisms. Fluoroquinolones with metronidazole
      • Cefepime or ceftazidime with metronidazole
    • Image-guided aspiration and drainage
    • Surgical necrosectomy (debridement of pancreatic necrosis) if less-invasive measures are not successful

Pseudocyst

  • An encapsulated collection of fluid with a well-defined inflammatory wall
  • Occurs several weeks after the onset of pancreatitis
  • Most are asymptomatic, but some may have abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, early satiety, or jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice.
  • Diagnosis is made with US, CT, or magnetic resonance imaging (MRI)
  • Treatment:
    • Observation:
      • For those with minimal or no symptoms
      • Most will reduce in size or resolve
    • Drainage:
      • For those who are symptomatic or develop infection
      • Requires the wall of the pseudocyst to mature, which may take weeks

Abdominal compartment syndrome Compartment Syndrome Compartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space. Compartment Syndrome

  • Sustained intra-abdominal pressure with organ failure
  • Due to significant tissue edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and fluid resuscitation
  • Presentation:
    • Tense, distended, painful abdomen
    • Progressive oliguria
    • Hemodynamic instability
    • Pulmonary decompensation
  • Diagnosis is made by measuring the intra-abdominal pressure.
  • Treatment:
    • Hemodynamic support
    • Pain control
    • Surgical decompression

Pseudoaneurysm

  • Results from the erosion of the gastroduodenal or splenic artery into a pseudocyst
  • Rare, but life threatening
  • Presents with unexplained gastrointestinal bleeding Gastrointestinal bleeding Gastrointestinal bleeding (GIB) is a symptom of multiple diseases within the gastrointestinal (GI) tract. Gastrointestinal bleeding is designated as upper or lower based on the etiology's location to the ligament of Treitz. Depending on the location of the bleeding, the patient may present with hematemesis (vomiting blood), melena (black, tarry stool), or hematochezia (fresh blood in stools). Gastrointestinal Bleeding and anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
  • Angiography for diagnosis and embolization

Splanchnic venous thrombosis

  • Thrombosis of the splenic, portal, or superior mesenteric veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
  • Splanchnic venous thrombosis is, many times, found incidentally on imaging.
  • Treatment:
    • Treat the underlying pancreatitis.
    • Anticoagulation if compromising hepatic function or bowel perfusion

Acute respiratory distress syndrome ( ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome)

  • Respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure with widespread alveolar damage and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs:
    • Mediated by cytokines and inflammatory cells
    • Caused by systemic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation from acute pancreatitis
  • Mortality rate of 30%–40%
  • Chest radiograph will show diffuse, bilateral opacities.
  • Treatment:
    • Oxygen supplementation:
      • High-flow nasal cannula
      • Mechanical ventilation
    • Conservative fluid management

Differential Diagnosis

  • Acute cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract resulting from sustained gallstone impaction of the cystic duct. Patients present with colicky, upper abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, nausea, and vomiting. Inflammation of the gallbladder Gallbladder The gallbladder is a pear-shaped sac, located directly beneath the liver, that sits on top of the superior part of the duodenum. The primary functions of the gallbladder include concentrating and storing up to 50 mL of bile. Gallbladder and Biliary Tract and gallstones are seen on US or CT. Amylase and lipase are usually not elevated, which differentiates acute cholecystitis Cholecystitis Cholecystitis is the inflammation of the gallbladder (GB) usually caused by the obstruction of the cystic duct (acute cholecystitis). Mechanical irritation by gallstones can also produce chronic GB inflammation. Cholecystitis is one of the most common complications of cholelithiasis but inflammation without gallstones can occur in a minority of patients. Cholecystitis from acute pancreatitis. Treatment includes IVF IVF Intravenous fluids (IVFs) are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids, antibiotics, and cholecystectomy. 
  • Perforated peptic ulcer disease Peptic ulcer disease Peptic ulcer disease (PUD) refers to the full-thickness ulcerations of duodenal or gastric mucosa. The ulcerations form when exposure to acid and digestive enzymes overcomes mucosal defense mechanisms. The most common etiologies include Helicobacter pylori (H. pylori) infection and prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Peptic Ulcer Disease: complete erosion of an ulcer through the wall of the stomach Stomach The stomach is a muscular sac in the upper left portion of the abdomen that plays a critical role in digestion. The stomach develops from the foregut and connects the esophagus with the duodenum. Structurally, the stomach is C-shaped and forms a greater and lesser curvature and is divided grossly into regions: the cardia, fundus, body, and pylorus. Stomach or duodenum. Patients present with severe epigastric pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, tachycardia, and abdominal rigidity. Lipase and amylase may be elevated, but not to the degree seen in acute pancreatitis. Diagnosis relies on imaging, which will show extraluminal gas. Patients require antibiotics and emergency surgery for repair. 
  • Acute mesenteric ischemia Mesenteric Ischemia Mesenteric ischemia is a rare, life-threatening condition caused by inadequate blood flow through the mesenteric vessels, which results in ischemia and necrosis of the intestinal wall. Mesenteric ischemia can be either acute or chronic. Mesenteric Ischemia: tissue injury caused when perfusion fails to meet the demands of the intestines, usually due to an embolism or thrombosis. Patients have periumbilical pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain out of proportion to the exam. Computed tomography with angiography is used to detect vessel stenosis or occlusion. Lipase can be elevated, but not to the degree seen in acute pancreatitis. Acute ischemia requires revascularization and resection of the infarcted bowel.
  • Pancreatic cancer: a neoplasm of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas. Symptom onset is more insidious, and patients may have unrelenting epigastric pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, weight loss, and jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice. The diagnosis is confirmed with imaging. The history, exam, and imaging will differentiate pancreatic cancer from acute pancreatitis. Treatment is usually aggressive because tumors are usually found late, and includes chemotherapy, radiation, and surgery. Prognosis for survival is generally poor.

References

  1. Tang, J.C.F., & Markus, J.T. (2019). Acute pancreatitis. In Anand, B.S. (Ed.), Medscape. Retrieved  November 8, 2020, from https://emedicine.medscape.com/article/181364-overview
  2. Vege, S.S. (2019). Clinical manifestations and diagnosis of acute pancreatitis. In Grover, S. (Ed.), UpToDate. Retrieved November 8, 2020, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-acute-pancreatitis
  3. Vege, S.S. (2019). Etiology of acute pancreatitis. In Grover, S. (Ed.), Uptodate. Retrieved November 9, 2020, from https://www.uptodate.com/contents/etiology-of-acute-pancreatitis
  4. Vege, S.S. (2019). Management of acute pancreatitis. In Grover, S. (Ed.), Uptodate. Retrieved November 9, 2020, from https://www.uptodate.com/contents/management-of-acute-pancreatitis
  5. Vege, S.S. (2019). Pathogenesis of acute pancreatitis. In Grover, S. (Ed.), Uptodate. Retrieved November 9, 2020, from https://www.uptodate.com/contents/pathogenesis-of-acute-pancreatitis
  6. Bartel, M. (2020). Acute pancreatitis. [online] MD Professional Version. https://www.msdmanuals.com/professional/gastrointestinal-disorders/pancreatitis/acute-pancreatitis

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