Updated: 11/5/2019

Acute Pancreatitis

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Snapshot
  • A 50-year-old man presents to the emergency room with acute onset epigastric pain. His past medical history includes hyperlipidemia, hypertriglyceridemia, diabetes, and alcohol abuse. His last drink was this morning and he drinks 20 beers a day. He denies any fevers or chills but reports nausea and 2 episodes of nonbloody, nonbilious vomiting. Physical exam is notable for tenderness to palpation of the epigastrium. There is no muscle spasm with percussion of the cheeks. Laboratory evaluation shows significantly elevated amylase and lipase. He is started on aggressive fluid resuscitation.  
Introduction
  • Clinical definition
    • acute inflammation of pancreas and surrounding tissue, often by autodigestion with pancreatic enzyme leakage
  • Epidemiology
    • risk factors
      • gallstones (more common)
      • heavy alcohol use (more common)
      • electrolyte abnormalities
        • ↑ serum calcium
      • ↑ triglycerides
      • trauma
      • drugs
        • thiazides
        • sulfa drugs
        • NRTIs
        • protease inhibitors
        • statins
        • valproic acid 
        • many others
      • viral infections
        • mumps
      • autoimmune disease
      • endoscopic retrograde cholangiopancreatography (ERCP)
      • scorpion sting
  • Pathogenesis
    • inflammation is caused by leakage of pancreatic enzymes into pancreatic tissue
    • causes autodigestion of pancreas and surrounding tissue
  • Prognosis
    • Ranson criteria predict mortality
Ranson Criteria
Clinical Signs
On Admission
Within 48 hours
  • Glucose > 200 mg/dL
  • Age > 55 years
  • LDH > 350 IU/L
  • WBC > 16,000/mL
  • AST > 250 IU/dL
  • Calcium < 8.0 mg/dL
  • Hematocrit ↓ by >10%
  • PaO2 < 60 mmHg
  • Base deficit > 4 mEq/L
  • BUN ↑ by 5 mg/dL
  • Sequestered fluid > 6 L
Mortality
  • 3-4 signs
  • 20% mortality
  • 5-6 signs
  • 40% mortality
  • 7+ signs
  • 100% mortality

Presentation
  • Symptoms
    • sudden onset epigastric pain radiating to the back
    • nausea and vomiting
    • systemic inflammation
      • fever
      • chills
  • Physical exam
    • inspection
      • flank ecchymosis
        • Grey Turner sign
      • periumbilical ecchymosis
        • Cullen sign
          • seen in
            • acute pancreatitis
            • hemorrhagic pancreatitis
            • hemorrhage 
    • palpation
      • epigastric tenderness
Studies
  • Diagnostic testing
    • imaging
      • abdominal radiograph
        • findings
          • sentinel loop
            • isolated and dilated loop of bowel seen in inflammatory conditions
      • abdominal ultrasound
        • indication
          • all patients
          • to assess for gallstones
        • findings
          • enlarged pancreas
          • abscess
          • gallstones
      • computed tomography (CT) of abdomen and pelvis with contrast
        • indications
          • diagnosis uncertain
          • failure to improve clinically
          • presence of Grey Turner or Cullen sign, as this may indicate hemorrhagic pancreatitis
        • findings
          • enlarged pancreas
          • indistinct margins (due to inflammation)
          • necrosis
          • peripancreatic fluid
          • pseudocyst
          • abscess
      • CT-guided fine-needle aspiration
        • indications
          • infected necrosis
          • for Gram stain and culture to guide antibiotic selection
    • studies
      • ↑ amylase
      • ↑ lipase
      • ↓ calcium
  • Diagnostic criteria
    • diagnosis by 2 or more of the following
      • acute-onset epigastric pain
      • ↑ serum amylase or lipase to 3x upper limit of normal
      • imaging suggestive of pancreatitis
Differential
  • Peptic ulcer disease
    • distinguishing factor
      • also presents with epigastric pain but will not have elevations in pancreatic enzymes
Treatment
  • Management approach
    • remove all offending agents when possible
    • treatment will be guided by etiology of pancreatitis
  • First-line
    • supportive care
      • fluid resuscitation
      • electrolyte repletion
      • analgesia
      • bowel rest but feed as soon as tolerated
      • nasogastric decompression
    • intravenous antibiotics
  • Other treatments
    • endoscopic retrograde cholangiopancreatography (ERCP) with eventual cholecystectomy
      • indication
        • gallstone pancreatitis
    • surgical debridement
      • indication
        • symptomatic necrotizing pancreatitis
Complications
  • Pancreatic pseudocyst
  • Fistula formation
  • Pancreatic abscess
  • Hemorrhagic pancreatitis
  • Pleural effusions (often on the left)
  • Chronic pancreatitis
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.4694) A 45-year-old man with a history of biliary colic presents with one-day of intractable nausea, vomiting, and abdominal pain radiating to the back. Temperature is 99.7 deg F (37.6 deg C), blood pressure is 102/78 mmHg, pulse is 112/min, and respirations are 22/min. On abdominal exam, he has involuntary guarding and tenderness to palpation in the right upper quadrant and epigastric regions. Laboratory studies show white blood cell count 18,200/uL, alkaline phosphatase 650 U/L, total bilirubin 2.5 mg/dL, amylase 500 U/L, and lipase 1160 U/L. Which of the patient's laboratory findings is associated with increased mortality? Review Topic

QID: 107797
1

White blood cell count

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(0/0)

2

Alkaline phosphatase

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3

Total bilirubin

0%

(0/0)

4

Amylase

0%

(0/0)

5

Lipase

0%

(0/0)

M2

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(M2.GI.4692) A 39-year-old male presents to the emergency department with acute abdominal pain and anorexia for two days. The patient has an extensive history of alcoholism with a hospitalization four months ago after being brought in by the police department for intoxication. On physical exam vital signs are T 99.0 F, BP 100/68 mmHg, HR 135 bpm, RR 20 rpm, and O2 Sat 100%. Abdominal exam is notable for exquisite tenderness to palpation over the epigastrium and the following finding (Figure A). Therapy for this patient should consist of which of the following? Review Topic

QID: 107669
FIGURES:
1

Endoscopic retrograde cholangiopancreatography (ERCP)

0%

(0/2)

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IV fluid hydration, analgesia, and intensive care management

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Treat with chlordiazepoxide and intensive care management

50%

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4

Esophagogastroduodenoscopy (EGD) with variceal banding

0%

(0/2)

5

Percutaneous transhepatic cholangiography (PTC)

50%

(1/2)

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(M2.GI.14) A 37-year-old woman with a past medical history diabetes, high cholesterol, hypertension and anxiety complains of rapid-onset, mid-epigastric pain with radiation to the back. She states that she has had a few of these episodes in the past, but this is the worst so far. Her pain is somewhat relieved by sitting forward. Physical examination notes epigastric tenderness without guarding or rebound. Figure A is also noticed on physical examination. Laboratory studies show elevated amylase and lipase. She denies use of alcohol, tobacco, and illicit drugs. A RUQ ultrasound was performed and found to be negative and total and direct bilirubin are normal. Urine toxicology returns negative results and her blood alcohol level is determined to be 0. What is the most likely cause of her current symptoms? Review Topic

QID: 104556
FIGURES:
1

Alcoholism

6%

(5/77)

2

Scorpion sting

3%

(2/77)

3

Biliary tract obstruction

14%

(11/77)

4

Hypertriglyceridemia

73%

(56/77)

5

Hypercalcemia

3%

(2/77)

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