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 ETIOLOGY Pathogenesis inflammation is caused by leakage of pancreatic enzymes into pancreatic tissue causes autodigestion of pancreas and surrounding tissue 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 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 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 Diagnostic testing studies ↑ amylase ↑ lipase ↓ calcium Differential Peptic ulcer disease distinguishing factor also presents with epigastric pain but will not have elevations in pancreatic enzymes DIAGNOSIS 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 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 with cholangitis common bile duct obstruction surgical debridement indication symptomatic necrotizing pancreatitis Complications Pancreatic pseudocyst Fistula formation Pancreatic abscess Hemorrhagic pancreatitis Pleural effusions (often on the left) Chronic pancreatitis Disseminated intravascular coagulation (DIC) Prognosis Ranson criteria predict mortality Ranson CriteriaClinical SignsOn AdmissionWithin 48 hoursGlucose > 200 mg/dLAge > 55 yearsLDH > 350 IU/LWBC > 16,000/mLAST > 250 IU/dLCalcium < 8.0 mg/dLHematocrit ↓ by >10%PaO2 < 60 mmHgBase deficit > 4 mEq/LBUN ↑ by 5 mg/dLSequestered fluid > 6 LMortality3-4 signs20% mortality5-6 signs40% mortality7+ signs100% mortality Clinical Signs On Admission Within 48 hours Glucose > 200 mg/dL Age > 55years 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 On Admission Within 48 hours 3-4 signs 20% mortality 5-6 signs 40% mortality 7+ signs 100% mortality