Sandbox3

Management

Signs & symptoms: severe abdominal pain, breathing difficulty, hypotension, vomiting, fever, cullen's sign, grey turner sign

Hemodynamic stability?

Unstable

{{{ E03 }}}

Stable

Trans abdominal USG

Labs: BUN, CBC, CXR, HCT, serum amylase, serum lipase, serum triglycerides, sr. creatinine

Diagnostic criteria: Any 2 out of 3 Abdominal pain consistent with disease serum amylase or lipase values > 3 times normal consistent findings from abdominal imaging

Acute Pancreatitis

SIRS?

{{{ yes }}}

No

Risk stratification (Marshall scoring)

Lower risk

Higher risk

Admit to medical ward

Admit to ICU

Fluids: Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs Reassess within 6 hrs after admission and for next 24-48 hrs Analgesics: Opioids are preferred, Mepridine & Morphine may be used as IV drips/pt. controlled analgesia Nutrition: Immediate oral feeding as soon as pain, vomiting, nausea subside

Fluids: Initiate with a fluid bolus Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs Reassess within 6 hrs after admission and for next 24-48 hrs Analgesics: Opioids are preferred, Mepridine & Morphine may be used as IV drips/pt. controlled analgesia Nutrition: Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside Consider enteral feeding if above not tolerated

Cholangitis or biliary obstruction

{{{ YES }}}

ERCP within 24 hrs/Cholecystectomy to prevent recurrence

No

Consider MRCP/EUS

Clinical improvement within 48-72 hrs

{{{ YES }}}

Assess for ability to maintain oral feeding at the end of 1 week

N o

CECT/MRI

Recovery

Pancreatic necrosis

Failure to improve clinically after 7-10 days of hospitalization

Yes

Supportive treatment

No

Suspect Infected necrosis

CT guided FNA Empiric antibiotics, necrosis penetrating: meropenem 1g IV Q8h ciprofloxacin 400mg IV Q12h plus metronidazole 500 mg IV Q8h for 14 days

Gram stain & Culture (-)

Supportive treatment Consider repeat CT FNA every 7 days if no improvement

Gram stain & Culture(+)

Infected Necrosis

Clinically stable

Clinically unstable

Continue antibiotics & observe If asymptomatic no debridement, else consider surgical consultation

Prompt surgical consultation