Updated: 2/7/2019

Acute Pancreatitis

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Snap Shot
  • A 35-year-old man complains of rapid onset of midepigastric pain with radiation to the back after eating a large meal. Physical exam shows low grade fever, epigastric tenderness, and decreased bowel sounds. Abdominal CT scan shows localized dilation of the upper duodenum and a small collection of fluid in the left pleural cavity.
Introduction
  • Life threatening disease
  • Caused by leakage of pancreatic enzymes that autodigest the pancreas
  • More common in males and in a younger age group
  • 70% related to
    • gallstone disease 
    • alcohol
  • Etiologies include (PANCREATITIS)
    • Posterior perforation of peptic ulcer
    • Alcohol 
    • Neoplasm
    • Cholelithiasis, cholecystectomy, increased calcium
      • biliary tract obstruction
    • Renal disease
    • ERCP
    • Anorexia
    • Trauma
    • Infections
    • Toxins / drugs (thiazides, AZT, protease inhibitors) 
    • Incineration
    • Stings (Scorpion)
    • hypertriglyceridemia 
Presentation
  • Symptoms
    • severe epigastric pain
      • described as steady and boring
      • radiates to the back
      • relieved by leaning forward
    • nausea
    • vomiting
    • weakness
    • low fever (70-85%)
    • shock (20-40%, due to loss of fluid in peripancreatic third space)
  • Physical exam 
    • abdominal tenderness without guarding or rebound
    • diminished bowel sounds from a localized ileus
  • Hemorrhagic pancreatitis indicated by
    • Grey Turner's sign (purple discoloration of the flank) 
      • locate source of bleeding (CT scan) 
    • Cullen's sign (periumbilical purple discoloration)
  • Jaundice is rare
Evaluation
  • Labs  
    • elevated amylase:
      • elevated in 95% of acute attacks during the first 12-24hrs
      • initially increases 2-6 hours after onset of pain
    • elevated lipase
  • Imaging
    • AXR shows
      • sentinel loop
        • isolated, dilated loop of bowel seen in inflammatory conditions
        • caused by inflammation irritating adjacent bowel
      • colon cutoff
    • CXR may shows left sided exudative pleural effusion (present in 10%)
    • CT and ultrasound show  
      • peripancreatic fluid
      • pancreatic calcifications
  • Ranson criteria
      used to determine prognosis
    • examines age, WBC count, glucose, LDH, AST, hematocrit, BUN, and calcium
Treatment
  • Acute management includes 
    • IV fluids
    • bowel rest
    • NG decompression
    • Abx (controversial)
  • Pain control
  • Surgical debridement if peripancreatic fluid
Prognosis, Prevention, and Complications
  • Prognosis is typically determined by CT scan
  • Some sources determine prognosis based on Ranson's 11 criteria: 

    Ranson's Criteria
    On Admission Within 24-48 hours
    Age > 55 years
    • HCT drops > 10%
    • BUN increase by 5 mg/dL after resuscitation
    • Serum Ca < 8mg/dL
    • Arterial PaO2 < 60mmHg
    • > 6 L fluid deficit
    • Base deficit > 4 mEq/L
    • Note: amylase and lipase not prognostic
    WBC > 16,000/μL
    AST > 250 IU/dL
    LDH > 350 IU/L
    Blood glucose > 200 mg/dL
    Risk of Mortality
    3-4 signs
    • 20%
    5-6 signs
    • 40%
    > 7 signs
    • 100%
  • Patients often require ICU and the condition may be fatal
  • Pulmonary complications
    • pleural effusions
    • atelectasis
    • mediastinal abscess
    • ARDS
  • Pseudocyst
  • Chronic pancreatitis
  • Splenic vein throbosis
    • gastric varices in absence of esophageal varices
  • Multiple episodes increase risk of pancreatic cancer 
 

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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
Calculator

(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

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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

7%

(5/75)

2

Scorpion sting

3%

(2/75)

3

Biliary tract obstruction

15%

(11/75)

4

Hypertriglyceridemia

72%

(54/75)

5

Hypercalcemia

3%

(2/75)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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%

(0/0)

2

IV fluid hydration, analgesia, and intensive care management

0%

(0/0)

3

Treat with chlordiazepoxide and intensive care management

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4

Esophagogastroduodenoscopy (EGD) with variceal banding

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(0/0)

5

Percutaneous transhepatic cholangiography (PTC)

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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