Acute Pancreatitis with Case

00:00 Welcome. Today we will discuss disorders of the pancreas.

00:05 So, we'll begin right away with a case.

00:08 A 38-year-old man is evaluated in the ED for acute epigastric pain.

00:14 The pain began four hours ago, radiates to the back and is associated with nausea and bilious vomiting.

00:20 He has no medical conditions. He drinks six beers a day.

00:24 Vitals are notable for a heart rate of 110 and a respiratory rate of 25.

00:29 He has epigastric tenderness without guarding or rebound.

00:33 Bowel sounds are hypoactive. No jaundice is noted.

00:37 His lab studies reveal a white cell count of 18,000 and a serum lipase of 1600.

00:44 Abdominal ultrasound shows a normal gallbladder without biliary dilatation.

00:49 What are the best initial steps in management? So let's look at some key items in this case.

00:55 He has acute abdominal pain radiating to the back.

00:59 And he's a patient with known alcohol use disorder.

01:02 In addition, his vitals are notable for tachycardia and tachypnea.

01:07 And he has leukocytosis indicating SIRS or systemic inflammatory response syndrome.

01:13 His labs otherwise are notable for an elevated serum lipase.

01:18 And he has a normal gallbladder on his ultrasound.

01:22 So, before we talk about management, let's talk about acute pancreatitis.

01:28 How does acute pancreatitis occur? So, the pathogenesis of pancreatitis begins with an obstruction of the pancreatic duct or some trigger for pancreatic inflammation.

01:41 Blockage of the pancreatic duct to then leads to premature activation of the pancreatic enzymes that are normally secreted to help with digestion.

01:50 When these enzymes are secreted and they have nowhere to go, they then begin to auto digests the pancreas and create a lot of local inflammation.

02:01 This then can contribute to capillary leak syndrome and ultimately SIRS or systemic inflammatory response syndrome which can appear as like sepsis.

02:12 And in the worst-case scenario can develop multi-organ failure.

02:17 There are many different causes of acute pancreatitis.

02:22 One mnemonic that I find helpful and that you will probably will encounter is the, IGETSMASHED mnemonic.

02:29 This stands for idiopathic, gallstones, ethanol and trauma and all of the etiologies you see here.

02:36 Note that about 80% of all cases are related to gallstones and ethanol.

02:44 If you don't remember this mnemonic, note that there are many causes that are listed here for your reference.

02:50 I will point out that many medications can cause pancreatitis some of which include hydrochlorothiazide, furosemide and azathioprine, so all medications that can be used commonly.

03:02 And infections can also cause pancreatitis including mumps, Coxsackie virus and cytomegalovirus.

03:09 So, the symptoms of acute pancreatitis usually include, severe upper abdominal pain which often radiates to the back because of the anatomic location of the pancreas.

03:20 Patients may present with fever and nausea and vomiting as well.

03:25 The diagnosis is made based on having at least two of the three following clinical criteria.

03:33 So, they must have an acute onset of upper abdominal pain.

03:38 They may also have a serum amylase or lipase greater than three times the upper limit of normal.

03:45 Or they may have characteristic findings of pancreatitis on imaging which can be either a CT with contrast, an MRI or ultrasound.

03:56 Here on the right, you can see an example of a CT of the abdomen showing acute pancreatitis.

04:02 So you see an edematous or swollen pancreas with adjacent fat stranding around it.

04:08 This is typical of acute pancreatitis on CT scan.

04:12 As a quick high-value care aside, you should not check for both amylase and lipase when you suspect acute pancreatitis.

04:23 A serum lipase is enough to make the diagnosis because it has better sensitivity and is elevated for longer than the amylase.

04:31 So just remember when faced with acute pancreatitis, just test for lipase.

04:37 So, now let's talk about the treatment and scoring severity of for acute pancreatitis.

04:43 There are several severity scoring systems we can use to help us determine a patient's prognosis.

04:49 They include the Apache II system and Ranson's criteria.

04:54 I'm not gonna go into detail about what they include, but you can easily look them up.

04:58 The management of acute pancreatitis depends mostly on aggressive IV fluid resuscitation.

05:05 You should remember that pancreatitis because of all of the inflammation occurring in the pancreatic tissues is similar to having a severe burn inside the body.

05:15 So, with this, we should provide aggressive fluids.

05:18 You also want to offer the patient to have a brief period of bowel rest.

05:24 Keep in mind that once the patient feels a little bit better and their nausea, vomiting and abdominal pain have improved, you can safely restart oral feeding.

05:33 If they continue to feel terribly and they're not able to eat after 72 hours, then evidence shows that starting enteral nutrition by either a nasogastric tube or a nasojejunal tube can improve the patient's outcome.

05:49 A third element of management is offering pain control as patients often have very severe pain.

05:56 And lastly, you want to also give antiemetics to help them with their nausea.

06:01 So, there are many complications that can occur from acute pancreatitis.

06:06 The first one is just a peripancreatic fluid collection.

06:10 This can happen early in the course of pancreatitis and usually resolved spontaneously.

06:16 So no special management is needed.

06:19 On the other hand, you may develop a pancreatic pseudocyst which occurs usually about four weeks or more after the first episode of pancreatitis and it is a persistent collection of fluid around the area.

06:32 We usually manage this by just observing the pseudocyst but if the patient becomes symptomatic or there is rapid enlargement of the pseudocyst, you may drain the pseudocyst.

06:45 The next complication is necrotizing pancreatitis.

06:50 This is when there is such severe inflammation that patients develop necrosis of the pancreas and any adjacent tissues.

06:57 This makes them also at very high risk for developing an infection to the area.

07:02 So, we manage them with providing broad-spectrum antibiotics if they deteriorate clinically.

07:09 Because of all of the local inflammation, patients may also present with splanchnic venous thrombosis.

07:16 So you may have a clot form and any of the veins surrounding the pancreas including the splenic vein, portal vein or the SMV.

07:23 The management is purely by treating the underlying inflammation or pancreatitis.

07:29 And lastly, one of the most dreaded complications of acute pancreatitis is abdominal compartment syndrome.

07:37 This is when the amount of inflammation within the abdomen has exceeded the pressure.

07:42 So, an intra-abdominal pressure of greater than 20 mmHg along with organ failure.

07:49 And we manage these patients with supportive care.

07:53 In very severe cases, we may need to do surgical decompression which involves opening the abdomen to allow relief of the high-pressure.

08:02 So, we can now talk about all of these complications in terms of imaging.

08:06 On imaging, you may see necrotizing pancreatitis shown here with an area of walled off necrosis.

08:14 The second thing you may see is a large collection of dark color fluid as shown here.

08:20 This -- if you see this after about four weeks after the initial pancreatitis episode, would be a pancreatic pseudocyst.

08:28 Next, you may see a specific type of splenic vein thrombosis leading to infarct of the spleen.

08:36 Here, you can see on the very innermost tip of the spleen a small area of darkening which is the area that has been infarcted because of a thrombosis.

08:48 And lastly, you may see evidence of ascites on imaging.

08:52 So here on CT, the dark areas of fluid in the free abdomen or peritoneum represents ascites.

09:00 So now let's return to our case.

09:05 We had a 38-year-old man who has now acute abdominal pain radiating to the back.

09:10 He has known alcohol use disorder.

09:12 He has SIRS or the systemic inflammatory response syndrome and an elevated serum lipase with a normal gallbladder on ultrasound.

09:21 So, if we put this all together, we can suspect that he has acute pancreatitis from his underlying alcohol use. He now has SIRS.

09:29 And importantly, since his gallbladder looks normal on ultrasound without any gallstones, we know that the alcohol was likely the trigger for his pancreatitis.

09:39 So the best initial steps in management include giving aggressive IV fluids, allowing for a brief period of bowel rest, so keeping patients NPO.

09:50 Offering pain control and antiemetics.