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| ==Management== | | ==Diagnostic Criteria== |
| | ▸ Diagnosis is established by the presence of two of the three following criteria:<ref name="Banks-2013">{{Cite journal | last1 = Banks | first1 = PA. | last2 = Bollen | first2 = TL. | last3 = Dervenis | first3 = C. | last4 = Gooszen | first4 = HG. | last5 = Johnson | first5 = CD. | last6 = Sarr | first6 = MG. |last7 = Tsiotos | first7 = GG. | last8 = Vege | first8 = SS. | last9 = Acosta | first9 = JM. | title = Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. | journal = Gut | volume = 62 | issue = 1 | pages = 102-11 | month = Jan | year = 2013 |doi = 10.1136/gutjnl-2012-302779 | PMID = 23100216 }}</ref> |
| | * '''Abdominal pain consistent with acute pancreatitis (acute onset of a persistent, severe epigastric pain often radiating to the back).''' |
| | <!-- |
| | ::* A dull, colicky pain located in the lower abdomen suggests an alternative etiology. |
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| | * '''Serum [[lipase]] or [[amylase]] ≥ 3 x ULN.''' |
| | <!-- |
| | ::* Amylase may be falsely elevated in [[appendicitis]], [[cholecystitis]], [[intestinal obstruction]] or [[Mesenteric ischemia|ischemia]], [[perforated ulcer]], [[salivary gland]] disease, gynecological disease, renal disease, and [[macroamylasemia]]. |
| | ::* Amylase may remain normal on admission in cases caused by alcohol and [[hypertriglyceridemia]], which occurs in as many as one-fifth of patients.<ref name="Clavien-1989">{{Cite journal | last1 = Clavien | first1 = PA. | last2 = Robert | first2 = J. | last3 = Meyer | first3 = P. | last4 = Borst | first4 = F. | last5 = Hauser | first5 = H. | last6 = Herrmann | first6 = F. | last7 = Dunand | first7 = V. | last8 = Rohner | first8 = A. | title = Acute pancreatitis and normoamylasemia. Not an uncommon combination. | journal = Ann Surg | volume = 210 | issue = 5 | pages = 614-20 | month = Nov | year = 1989 | doi = | PMID = 2479346 }}</ref><ref name="Winslet-1992">{{Cite journal | last1 = Winslet | first1 = M. | last2 = Hall | first2 = C. | last3 = London | first3 = NJ. | last4 = Neoptolemos | first4 = JP. | title = Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis. | journal = Gut | volume = 33 | issue = 7 | pages = 982-6 | month = Jul | year = 1992 | doi = | PMID = 1379569 }}</ref> |
| | ::* Lipase may be falsely elevated in [[appendicitis]], [[cholecystitis]], renal disease, and macrolipasemia. |
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| | * '''Characteristic findings on contrast-enhanced [[computed tomography|CT]], [[magnetic resonance imaging|MRI]], or transabdominal [[ultrasonography|US]].''' |
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| | ::* If abdominal pain strongly suggests acute pancreatitis but pancreatic enzyme is less than three times the upper limit of normal, a confirmatory imaging is required.<ref name="Bollen-2007">{{Cite journal | last1 = Bollen | first1 = TL. | last2 = van Santvoort | first2 = HC. | last3 = Besselink | first3 = MG. | last4 = van Es | first4 = WH. | last5 = Gooszen | first5 = HG. | last6 = van Leeuwen | first6 = MS. | title = Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. | journal = Semin Ultrasound CT MR | volume = 28 | issue = 5 | pages = 371-83 | month = Oct | year = 2007 | doi = | PMID = 17970553 }}</ref><ref name="Morgan-2008">{{Cite journal | last1 = Morgan | first1 = DE. | title = Imaging of acute pancreatitis and its complications. | journal = Clin Gastroenterol Hepatol | volume = 6 | issue = 10 | pages = 1077-85 | month = Oct | year = 2008 | doi = 10.1016/j.cgh.2008.07.012 | PMID = 18928934 }}</ref> |
| | ::* If the diagnosis is established by abdominal pain and elevated pancreatic enzyme, a CECT is not usually required on admission. |
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| {{familytree/start |summary=Acute Pancreatitis}}
| | <div class="mw-collapsible mw-collapsed"> |
| {{familytree | | | | | | | | | | | | | A01 |-|-|-|-|-|-|-|-|-|-|-|-|.| |A01='''Signs & symptoms''': severe abdominal pain, breathing difficulty, hypotension, vomiting, fever, [[cullen's sign]], [[grey turner sign]]}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | |!| |}}
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| {{familytree | | | | | | | | | | | | | E01 | | | | | | | | | | | | |!| | |E01=Hemodynamic stability? }}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | |!| |}}
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| {{familytree |border=0 | | | | | | | | | | | | | Z01 | | | | | | | | | | | | Z02 | | | | |Z01 = Stable|Z02= Unstable }}
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| {{familytree | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | |!| |}}
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| {{familytree | | | | | | B01 | | | | | | | | | | | | B02 | | | | | B03 |B01=Trans abdominal USG |B02='''Labs''': BUN, CBC, CXR, HCT, serum amylase, serum lipase, serum triglycerides, sr. creatinine |B03=Need to create hyperlink here }}
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| {{familytree | | | | | | |`|-|-|-|-|-|-|v|-|-|-|-|-|-|'| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | |C01='''Diagnostic criteria''': Any 2 out of 3<br><br> Abdominal pain consistent with disease<br><br>serum amylase or lipase values > 3 times normal<br><br>consistent findings from abdominal imaging}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | |D01=Acute Pancreatitis}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | F01 |-|-|-|-|-| F02 |-|.| | | | |F01=SIRS? |F02=Yes|"border=0" }}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | |!| | | | |}}
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| {{familytree |border=0 | | | | | | | | | | | | | AA1 | | | | | | | | | |!| | | | |AA1=No}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | |!| | | | |}}
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| {{familytree | | | | | | | | | | | | | G01 | | | | | | | | | |!| | | | |G01=Risk stratification (Marshall scoring)}}
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| {{familytree | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | |!| | | | |}}
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| {{familytree | | | | | | H01 | | | | | | | | | | | | H02 | | |!| | | | |H01=Lower risk |H02=Higher risk}}
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| {{familytree | | | | | | |!| | | | | | | | | | | | | |!| | | |!| | | | |}}
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| {{familytree | | | | | | I01 | | | | | | | | | | | | I02 |-|-|'| | | | |I01= Admit to medical ward |I02=Admit to ICU}}
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| {{familytree | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | J01 | | | | | | | | | | | | J02 | | | | | | | |J01= Fluids: Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs <br> Reassess within 6 hrs after admission and for next 24-48 hrs <br><br> Analgesics: Opioids are preferred, Mepridine & Morphine may be used as IV drips/pt. controlled analgesia <br><br> Nutrition: Immediate oral feeding as soon as pain, vomiting, nausea subside |J02=Fluids: Initiate with a fluid bolus<br> Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs <br> Reassess within 6 hrs after admission and for next 24-48 hrs <br><br>Analgesics: Opioids are preferred, Mepridine & Morphine may be used as IV drips/pt. controlled analgesia <br><br> Nutrition: Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside <br> Consider enteral feeding if above not tolerated}}
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| {{familytree | | | | | | |`|-|-|-|-|-|-|v|-|-|-|-|-|-|'| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | K01 |-|-|-|-|-| K02 |-|-|-|-| K03 |K01=Cholangitis or biliary obstruction |K02=Yes |K03=ERCP within 24 hrs/Cholecystectomy to prevent recurrence }}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree |border=0 | | | | | | | | | | | | | AK1 | | | | | | | | |AK1=No | | | | | |}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | L01 | | | | | | | | | | | | | | |L01=Consider MRCP/EUS}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | M01 |-|-|-|-|-| M02 |-|-|-|-| M03 |M01=Clinical improvement within 48-72 hrs |M02=Yes |M03=Assess for ability to maintain oral feeding at the end of 1 week}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |!|}}
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| {{familytree |border=0 | | | | | | | | | | | | | AE1 | | | |AE1=N o | | | | | | | | | | |!|}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | |!|}}
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| {{familytree | | | | | | | | | | | | | N01 | | | | | | | | | | | | | N02 | | | | |N01=CECT/MRI |N02=Recovery}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | O01 | | | | | | | | | | | | | | |O01=Pancreatic necrosis}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | P01 |-|-|-|-|-| P02 |-|-|-|-| P03 |P01=Failure to improve clinically after 7-10 days of hospitalization|P02=Yes|P03=Supportive treatment|}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree |border=0 | | | | | | | | | | || | AF1 | | | | |AF1=No | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | Q01 | | | | | | | | | | | | | | |Q01=Suspect Infected necrosis}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | R01 |-|-|-|-| R02 |-|-|-|-| R03 |R01=CT guided FNA <br><br> Empiric antibiotics, necrosis penetrating: <br><br>meropenem 1g IV Q8h <br><br> ciprofloxacin 400mg IV Q12h plus metronidazole 500 mg IV Q8h for 14 days |R02=Gram stain & Culture (-) |R03=Supportive treatment<br> Consider repeat CT FNA every 7 days if no improvement }}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree |border=0 | | | | | | | | | | | | | | AG1 | | | | | | |AG1=Gram stain & Culture(+) | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | S01 | | | | | | | | | | | | | | |S01=Infected Necrosis}}
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| {{familytree | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | | |}}
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| {{familytree | | | | | | T01 | | | | | | | | | | | | T02 | | | | | | | |T01=Clinically stable|T02=Clinically unstable}}
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| {{familytree | | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | U01 | | | | | | | | | | | | U02 | | | | | | | |U01=Continue antibiotics & observe <br> If asymptomatic no debridement, else consider surgical consultation |U02=Prompt surgical consultation}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree/end}}
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