key: cord-0035285-jwm0s8gm authors: Mishra, Ajay Kumar title: Acute Pancreatitis date: 2016-02-22 journal: Clinical Pathways in Emergency Medicine DOI: 10.1007/978-81-322-2710-6_27 sha: e7ae055247622a66d272904551d27c9a4f2504fc doc_id: 35285 cord_uid: jwm0s8gm Early diagnosis and treatment are crucial in the management of acute pancreatitis to prevent complications and to reduce morbidity and mortality. • Acute pancreatitis (AP) is an acute infl ammatory process in which there is autodigestion of pancreas by its own enzyme. • Annual incidence of AP varies between 4.9 and 73.4 cases per 100,000 worldwide with an increasing trend in the annual incidence [ 1 , 2 ] . Even though the case fatality rate for AP has decreased over time, the overall population mortality rate for AP has remained unchanged [ 3 ] . • Aetiological variation has been seen depending upon the lifestyle in different population. • Early diagnosis and treatment are crucial in the management of acute pancreatitis to prevent complications and to reduce morbidity and mortality. • Other life-threatening conditions which mimic acute pancreatitis should also be considered and ruled out simultaneously while managing the patient. • Prophylactic antibiotics are not indicated in sterile pancreatic necrosis. • Consider early admission in intensive care unit after initial resuscitation in the emergency department. • Generally, acute pancreatitis is more common in males than females. In males, the aetiology is more often related to alcohol; in females, it is more often related to biliary tract disease. • The overall mortality in patients with acute pancreatitis is 10-15 %. Mortality due to biliary pancreatitis is high as compared to alcoholic pancreatitis. Twenty percent of patients present with severe disease (organ failure) in whom, mortality is approximately 30 % [ 4 ] . Pathophysiology ( Fig. 27 .1 ) • The causes of acute pancreatitis have been listed in Table 27 .1 [ 5 -8 ] . • Cholelithiasis is the most common cause of acute pancreatitis (40-70 %), whereas alcohol is the second most common cause (25-35 %) [ 9 -11 ] . • Revised Atlanta criteria 2013 (Table 27. 2 ) defi nes severity of acute pancreatitis into three categories -mild acute pancreatitis, moderately severe acute pancreatitis and severe acute pancreatitis [ 12 ] . • Local complications include peripancreatic fl uid collections and pancreatic/peripancreatic necrosis (sterile or infected). • Organ failure is defi ned as a score of 2 or more using the modifi ed Marshall scoring system (Table 27. 3 ) [ 12 , 13 ] . • Phases of severe pancreatitis [ 14 , 15 ] : -Early -usually last for the fi rst week in which patient may present with systemic infl ammatory response syndrome (SIRS). -Late -follows the early phase and lasts from weeks to months, usually characterised by local complications and/or persistent organ failure. • Most patients with severe pancreatitis present to emergency department during the early phase without any signs of organ failure and local complications, thus leading to errors in clinical management of this disease [ 16 ] . Activation of zymogen activation cascade & release of inflammatory mediators (TNF-α, IL-6, IL-8) • -Cullen sign -bluish discolouration around the umbilicus due to haemoperitoneum -Grey Turner's sign -reddish-brown discolouration along the fl anks resulting from retroperitoneal haemorrhage (Fig. 27. 2 ) Any acute abdomen or sometimes cardiac as well as pulmonary conditions can mimic AP. Some of the common differentials are enlisted in the box below. • The diagnosis of AP should be considered in presence of two of the following three criteria: I. Typical abdominal pain suggestive of AP II. Serum amylase and/or serum lipase more than three times the upper limit of normal value III. Characteristic feature of AP in abdominal imaging • Detailed history should be taken to fi nd out the cause of AP, including history of alcohol consumption, hyperlipidaemia, similar episodes in the past, abdominal trauma and past history of gallstones or ERCP. Medication history should be asked to rule out drug induced AP. • Apart from serum amylase and lipase, complete blood count including haematocrit, liver function test, serum triglyceride levels, serum calcium, blood urea nitrogen (BUN) and serum electrolytes should be checked to look for aetiology as well as to assess severity of AP. • Serum triglyceride level of >1000 mg/dl is considered signifi cant as a cause of AP in absence of gallstones and history of alcohol abuse. • ECG -to rule out acute coronary syndrome. • Chest x-ray erect view to look for air under diaphragm in case of intestinal perforation and also to aid to diagnosis of any pulmonary pathology, e.g. ARDS. • In female patients under reproductive age group, bedside urine pregnancy card test should be done to rule out ectopic pregnancy. • Transabdominal ultrasound should be done in all patients of AP to look for possible causes [ 17 ] . • In patients >40 years of age without any identifi able cause of AP, pancreatic tumours should be suspected as a probable cause [ 18 , 19 ] . • Acute mesenteric ischaemia • Perforated gastric or duodenal ulcer • Dissecting aortic aneurysm • Biliary colic • Acute myocardial ischaemia • Ectopic pregnancy • Intestinal obstruction • ARDS • Contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the abdomen should be done only in patients in whom diagnosis is not certain or in those patients who do not show any signs of improvement within 48-72 h of hospital admission [ 20 ] . • Assess and stabilise airway, breathing and circulation. • Early aggressive intravenous hydration [ 21 ] with isotonic crystalloids to be started for all patients to correct hypovolaemia due to third spacing of fl uids, vomiting, reduced oral intake, increased respiratory loses and/or diaphoresis. Special precaution to be taken in patients with renal and/or cardiac disease. • Lactated Ringer's solution is the preferred crystalloid over 0.9 % normal saline for fl uid replacement [ 22 ] . • Adequate analgesia should be given at the earliest. Inj. morphine at a loading dose of 0.1 mg/kg body wt. followed by 0.05 mg/kg body wt. every 5 min can be administered until the pain is relieved [ 23 ] . • Nasogastric (NG) tube to be inserted and patient to be kept nil per orally (NPO) to give rest to the infl amed pancreas; however prolonged fasting should be avoided. Early oral feeding in acute pancreatitis is benefi cial in terms of shorter hospital stay, decreased infectious complications and decreased morbidity and mortality [ 24 ] . • Prophylactic antibiotics should not be given for severe AP and sterile necrosis [ 25 ] . Antibiotics should be given only if there is evidence of infected necrosis, extrapancreatic infection, cholangitis, bacteraemia, catheter-acquired infections, urinary tract infection and/or pneumonia. • ERCP should be done within 24 h of admission in patients with concurrent acute pancreatitis and acute cholangitis [ 26 ] . • Patients with moderately severe or severe acute pancreatitis should be admitted to an intensive care unit. (Fig. 27. 3 ) Acute pancreatitis is associated with emotional, physical, as well as fi nancial burden on the society [ 3 ] with signifi cant morbidity and mortality. Early diagnosis and early aggressive intravenous hydration can reduce morbidity and mortality as well as prevent complications. Contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) should be reserved for patients who fail to improve clinically or in whom diagnosis is not confi rmed. Patients with moderately severe or severe acute pancreatitis should be admitted to intensive care unit whenever possible. It is important to rule out other lifethreatening differential diagnosis of acute pancreatitis before shifting the patients from the emergency department. Clinically stable Clinically unstable/not improving • Early aggressive IV hydration. • Adequate analgesia. • NPO, NG tube with continuous dependent drainage. • Assess airway, breathing & circulation. • Insert large bore IV cannula. • Collect blood sample & send for CBC, RFT, LFT, serum electrolytes, serum amylase & lipase, serum calcium, serum triglyceride level. • Urine pregnancy test in female patients. • Obtain 12 lead ECG & chest X-ray erect position PA/AP view. Rule out life threatening differential diagnosis & manage accordingly. USG abdomen to look for aetiology & possible differential diagnosis. Plan to shift patient early to ICU. 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