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Management

Characterize the symptoms: ❑ severe abdominal pain and/or ❑ Breathing difficulty and/or ❑ Nausea & vomiting and/or ❑ Hiccups sometimes

Examine the paient: ❑ Fever and/or ❑ Hypotension and/or ❑ Cullen's sign and/or ❑ Grey-Turner's sign and/or ❑ Tachypnea and/or ❑ Abdominal distension and/or tenderness

Consider alternative diagnosis: ❑ Gallstones ❑ Dissecting aortic aneurysm ❑ Pancreatic pseudocyst

Hemodynamic stability?

Stable

Unstable

Order Labs: ❑ Blood urea nitrogen ❑ CBC ❑ Chest X-ray ❑ Hematocrit ❑ serum amylase ❑ serum lipase ❑ serum triglycerides ❑ serum creatinine Order imaging studies: Trans abdominal USG

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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