Pancreatitis Salient Points

Investigations

  • CT/MRI only indicated if
    • Diagnosis unclear from biochemistry or history
    • Failure to improve after 72 hours of admission
    • Suspicion of complications

Aetiology

  • GET SMASHED – gallstones, ethanol, trauma, salicylates, mumps, autoimmune, scorpion sting, hyperlipidemia, hypercalcemia and hypothermia, emboli, drugs
  • TA USS in all patients to look for gallstones
  • Lipids and calcium in the absence of a history suggestive of alcohol abuse and a normal TA USS
  • Unclear role for endoscopy

Risk stratification

  • Ranson and Glasgow scores. Ranson scores both at admission and 24 hours and is less useful for gallstone aetiologies
  • Glasgow score uses the mnemonic PANCREAS
    • P – PaO2 <8kPa
    • A – Age >55 years old
    • N – Neutrophilia – WCC >15×10(9)/L
    • C – Calcium <2 mmol/L
    • R – Renal function, Urea >16 mmol/L
    • E – Enzymes: LDH >600iu/L; AST >200iu/L
    • A – Albumin <32g/L (serum)
    • S – Sugar: blood glucose >10 mmol/L

ED management

  • Aggressive fluid resuscitation – up to 500ml/hour of CSL (third spacing)
  • Aim to normalize serum urea with fluid resuscitation

Inpatient management

  • Antibiotics
    • Not routinely indicated
    • Use for extra-pancreatic foci of infection or infected necrosis
  • Nutrition
    • Early low-fat feeding in mild pancreatitis as tolerated if N+V and abdominal pain have resolved
    • Enteric nutrition preferred over parenteral route in severe pancreatitis
    • No difference between NG and NJ tubes in severe pancreatitis
  • Surgery
    • Cholecystectomy if gallstones visualised in GB
    • If necrotising biliary pancretitis, defer until inflammation subsides
    • Surgery not indicated for asymptomatic pseudocysts and necrosis
    • In stable patients with infected necrosis, drainage should wait for 4/52 to allow for liquefaction and surrounding fibrosis
  • Infected necrosis
    • Difficult to distinguish sterile from infected necrosis
    • Reasonable strategy is to initiate empiric antibiotics while awaiting CT FNA
    • Inf patient stable, continue Abx, otherwise, send to theater for debridement
    • Tazocin or metronidazole + ceftriaxone are appropriate choices
  • ERCP
    • Acute cholangitis is an indication of urgent ERCP
    • Gallstone pancreatitis with no evidence of biliary obstruction should not receive ERCP
    • In the absence of cholangitis / obstruction, MRCP or endoscopic ultrasound (EUS) rather than diagnostic ERCP should be used to screen for
      choledocholithiasis
    • Pancreatic duct stents / postprocedure rectal SSAID suppositories should always be offered to prevent ERCP-induced pancreatitis

 

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One thought on “Pancreatitis Salient Points

  1. Pingback: Causes of acute Pancreatitis | Medicospace

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