Acute pancreatitis resident survival guide: Difference between revisions
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* Metabolic - [[hypercalcemia]] and [[hyperphosphatemia]] | * Metabolic - [[hypercalcemia]] and [[hyperphosphatemia]] | ||
* [[Smoking]]<ref name="Rebours-2012">{{Cite journal | last1 = Rebours | first1 = V. | last2 = Vullierme | first2 = MP. | last3 = Hentic | first3 = O. | last4 = Maire | first4 = F. | last5 = Hammel | first5 = P. | last6 = Ruszniewski | first6 = P. | last7 = Lévy | first7 = P. | title = Smoking and the course of recurrent acute and chronic alcoholic pancreatitis: a dose-dependent relationship. | journal = Pancreas | volume = 41 | issue = 8 | pages = 1219-24 | month = Nov | year = 2012 | doi = 10.1097/MPA.0b013e31825de97d | PMID = 23086245 }}</ref> | * [[Smoking]]<ref name="Rebours-2012">{{Cite journal | last1 = Rebours | first1 = V. | last2 = Vullierme | first2 = MP. | last3 = Hentic | first3 = O. | last4 = Maire | first4 = F. | last5 = Hammel | first5 = P. | last6 = Ruszniewski | first6 = P. | last7 = Lévy | first7 = P. | title = Smoking and the course of recurrent acute and chronic alcoholic pancreatitis: a dose-dependent relationship. | journal = Pancreas | volume = 41 | issue = 8 | pages = 1219-24 | month = Nov | year = 2012 | doi = 10.1097/MPA.0b013e31825de97d | PMID = 23086245 }}</ref> | ||
Revision as of 19:32, 29 November 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]
Definition
Acute pancreatitis is an acute inflammation of the pancreas characterized by severe abdominal pain and elevated pancreatic enzymes.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Acute pancreatitis from any cause may be life-threatening especially if it progresses to necrotizing pancreatitis. However, in last several years it has come down due to advances in diagnosis and treatment strategies.
Common Causes
- Idiopathic
- Ischaemic necrosis of pancreas from vascular sources such as vasculitis and atherosclerosis
- Medication such as 5-mercaptopurine, azathioprine, 5-DDI[1]
- Metabolic - hypercalcemia and hyperphosphatemia
- Post - ERCP
- Pregnancy
- Toxins such as venom of brown recluse spider, certain arachnids etc.
Management
| Acute Pancreatitis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Signs & symptoms: severe abdominal pain, breathing difficulty, hypotension, vomiting, fever, cullen's sign, grey turner sign | Check labs - serum amylase, serum lipase, serum triglycerides, abdominal USG, CBC, CECT, MRI | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Risk stratification | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Low risk | High risk | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| General medical ward | ICU | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Initiate supportive care Aggressive fluid resuscitation with 250-500 mlRingers Lactate per hr during first 12-24 hours In sever cases give fluid bolus Mild cases - oral liquid feeds In moderate to severe cases enteral feeds, nasogastric or nasojejunal feeds are acceptable | CT scan | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Provide adequate analgesia | Pancreatic necrosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Stones? | Other causes, treat as per cause | No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Surgical consult Emergency cholecystectomy or ERCP within 24 Hrs of admission | Assess in 1 week | SIRS/Organ failure? | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Tolerating oral feeds | Not tolerating oral feed | If yes, surgical consultation Think about CT guided percutaneous aspiration & culture | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Recovery | Add nutritional support Consider CT scan | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Lack of improvement/Worsening of clinical status | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Perform abdominal USG in all patients.
- Check serum triglycerides if stones/alcohol not not an etiology.
- Consider pancreatic tumor if age > 40 yrs.
- Use Ringer's Lactate(RL) as first choice agent, use normal saline if RL not available.
- Refer patients with idiopathic acute pancreatitis to centers of excellence.
- Perform elective cholecystectomy for gallstones to prevent recurrences.
Dont's
- Do not perform CECT/MRI routinely.
- Do not shift patients with sepsis/organ failure to general ward.
- Do not perform emergency surgery in stable patients with infected necrosis, wait for 3-4 weeks.
References
- ↑ Yi, GC.; Yoon, KH.; Hwang, JB. (2012). "Acute Pancreatitis Induced by Azathioprine and 6-mercaptopurine Proven by Single and Low Dose Challenge Testing in a Child with Crohn Disease". Pediatr Gastroenterol Hepatol Nutr. 15 (4): 272–5. doi:10.5223/pghn.2012.15.4.272. PMID 24010098. Unknown parameter
|month=ignored (help) - ↑ Rebours, V.; Vullierme, MP.; Hentic, O.; Maire, F.; Hammel, P.; Ruszniewski, P.; Lévy, P. (2012). "Smoking and the course of recurrent acute and chronic alcoholic pancreatitis: a dose-dependent relationship". Pancreas. 41 (8): 1219–24. doi:10.1097/MPA.0b013e31825de97d. PMID 23086245. Unknown parameter
|month=ignored (help) - ↑ Köhler, H.; Lankisch, PG. (1987). "Acute pancreatitis and hyperamylasaemia in pancreatic carcinoma". Pancreas. 2 (1): 117–9. PMID 2437571.
- ↑ Bleichner, JP.; Guillou, YM.; Martin, L.; Seguin, P.; Mallédant, Y. (1998). "-Pancreatitis after blunt injuries to the abdomen-". Ann Fr Anesth Reanim. 17 (3): 250–3. PMID 9750738.