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 login to view 1 more bullet ↑ triglycerides trauma drugs login to view 7 more bullets viral infections login to view 1 more bullet autoimmune disease endoscopic retrograde cholangiopancreatography (ERCP) scorpion sting Presentation Symptoms sudden onset epigastric pain radiating to the back nausea and vomiting systemic inflammation login to view 2 more bullets Physical exam inspection login to view 8 more bullets palpation login to view 1 more bullet imaging Abdominal radiograph findings login to view 2 more bullets Abdominal ultrasound indication login to view 2 more bullets findings login to view 3 more bullets Computed tomography (CT) of abdomen and pelvis with contrast indications login to view 3 more bullets findings login to view 6 more bullets CT-guided fine-needle aspiration indications login to view 2 more bullets Studies Diagnostic testing studies login to view 3 more bullets Differential Peptic ulcer disease distinguishing factor login to view 1 more bullet DIAGNOSIS Diagnostic criteria diagnosis by 2 or more of the following login to view 3 more bullets Treatment Management approach remove all offending agents when possible treatment will be guided by etiology of pancreatitis First-line supportive care login to view 5 more bullets intravenous antibiotics Other treatments endoscopic retrograde cholangiopancreatography (ERCP) with eventual cholecystectomy login to view 3 more bullets surgical debridement login to view 2 more bullets 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