Acute Pancreatitis

Adapted from NEJM 11/17/2016 review article “Acute Pancreatitis”:

CAUSES:

  1. Gallstones
  2. EtOH (must be chronic use, 4-5 drinks/d x >5y)
    1. Usu acute-on-chronic pancreatitis
    2. Binge drinking does not cause acute pancreatitis
  3. Drugs (<5%)
    1. azathioprine
    2. 6-mercaptopurine
    3. valproic acid
    4. ACEIs
    5. mesalamine
  4. Idiopathic
    1. more frequent with age

NON-CAUSES:

  • Sphincter of Oddi dysfunction
  • Pancreas divisum
  • Binge EtOH use (in absence of chronic use)

RISK FACTORS:

  • Genes (multiple genes associated)
  • Morbid obesity
  • T2DM (2-3 x baseline risk)
  • Smoking

DIAGNOSIS:  Must have 2 of 3:

  1. Abdominal pain consistent with acute pancreatitis (epigastric pain, non-colicky, boring, etc.)
  2. Amylase or lipase 2-3x ULN
  3. Imaging positive

Baseline mortality nowadays 2% – but persistent organ failure with infection, 30% mortality!

POOR PROGNOSTIC FACTORS:

  • Age > 60
  • Increased number of comorbidities
  • Obesity (BMI >30)
  • Chronic EtOH abuse
  • Elevated BUN and/or Cr
  • Elevated hematocrit
  • SIRS (T > 38C < 36C; P > 90; R >20 or pCO2 <32;  WBC <4K >12K) after 48h of symptom onset -> poor prognosis
  • In first 48-72h:  increasing hct, BUN or Cr, SIRS despite IVF resusc, necrosis on CT – suggestive of evolving severe acute pancreatitis

NOT HELPFUL FOR PROGNOSIS:

  • Severity of lipase or amylase elevation
  • CT findings (lag behind pathologic progression)

MANAGEMENT:

  1. IVF Resuscitation:  first 24 hours most important; aggressive IVF resusc improves morb and mort
    1. 200-500 mL/h or 5-10 mL/kgBW/hr -> usu 2.5 – 4L in 24 h
    2. One trial suggested LR > NS
    3. Take into account HF, renal function, etc. when following these guidelines
  2. Feeding:  TPN no better than enteral feeding, and early enteral feeding (<72h) not beneficial.
    1. Mild pancreatitis: start low-fat soft or solid diet ASAP
    2. Day 5:  if not tolerating PO, enteral feeds.  NJ = NG = ND approaches.
    3. TPN rarely needed
  3. Antibiotics:  don’t use prophylactically!  Use only if infection highly suspected or confirmed:  elev WBC, fever and worsening abd pain.
  4. Endoscopic Management
    1. ERCP for gallstone pancreatitis or choledocholithiasis
    2. Endo U/S: for pseudocyst or panc necrosis
  5. Fluid Collections / Necrosis
    1. Acute peripancreatic fluid collection -> no tx needed
    2. Symptomatic pseudocysts -> endoscopic tx
    3. Sterile necrosis -> no tx needed
    4. Infected necrosis (fever, inc WBC, inc abd pain, air on CT)
      1. Abx (broad-spectrum, covering GI bugs)
      2. Delay tx for 4 wks if possible to allow walling off
      3. Percutaneous drain as needed

LONG-TERM CONSEQUENCES OF ACUTE PANCREATITIS

  • 20-30% develop exo- and endocrine dysfunction
  • 1/3 to 1/2 of those (above) will develop chronic pancreatitis
  • More severe acute panc -> more likely chronic pancreatitis
  • Continued EtOH abuse and smoking -> inc risk of chronic pancreatitis:  encourage abstinence!

PREVENTION OF RELAPSE

  • Gallstone: Cholecystectomy during initial hospitalization – dec relapse risk by 75%
  • Gallstone: Don’t delay cholecystectomy for more than a few weeks!
  • EtOH: continued EtOH use -> risk of relapse 50%
  • Cont smoking -> inc risk of relapse
  • ERCP:  pancreatic duct stent or NSAID use
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