Pancreatitis
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Acute pancreatitis is a sudden inflammation of the pancreas.
Incidence
A.The incidence of acute pancreatitis ranges from 4.9 to 13/100,000 persons.
B.Leading gastrointestinal cause of hospitalization, with more than 300,000 admissions per year.
C.16.5% to 25% of patients experience recurrent episodes in the first several years post diagnosis.
D.Acute pancreatitis is frequently an isolated event, but may develop into chronic pancreatitis, particularly in the setting of chronic alcoholism.
E.60% to 90% of patients with pancreatitis have a history of chronic alcohol consumption; however, only a minority of alcoholics develop the disease.
F.Mortality rate for acute pancreatitis has remained the same over the past decade at 10%.
G.Optimal outcomes depend on recognition of acute pancreatitis as quickly as possible.
Pathogenesis
A.Gallstones and alcohol account for about 80% of all cases of acute pancreatitis.
B.Other causes of acute pancreatitis can be related to medications and very rarely to infections, trauma, or surgery of the abdomen. About 10% of cases are idiopathic.
1.Gallstones.
a.Gallstones can lodge in the common bile duct and cause obstruction of the pancreatic fluid by impinging on the main pancreatic duct.
b.Mechanism is not completely understood.
2.Alcohol.
a.Alcohol is metabolized by the pancreas and is thought to have a toxic effect on key cells.
b.Alcohol may also cause the production of excess collagen that contributes to fibrosis.
c.Large amounts of alcohol (80 g/day; approximately 10 to 11 drinks) for 6 to 12 years is required to produce symptomatic pancreatitis.
3.Medications.
a.Very rare and not well understood mechanism of how medications induce acute pancreatitis.
b.Possible theories include pancreatic duct constriction, cytotoxic, and metabolic effects.
c.Medications associated with acute pancreatitis.
i.Angiotensin-converting enzyme inhibitors.
ii.Statins.
iii.Oral contraceptives.
iv.Diuretics.
v.Valproic acid.
vi.Glucagon-like peptide 1 (GLP-1) hypoglycemic agents.
4.Trauma or surgery.
a.Injury to pancreas from trauma or surgery typically occurs from hemorrhage and sepsis related to primary injury.
b.Least commonly injured organ in abdominal trauma due in part to its location.
Predisposing Factors
A.Choledocholithiasis.
B.Chronic alcoholism.
C.Hypertriglyceridemia (greater than 1,000 mg/dL).
Subjective Data
A.Common complaints/symptoms.
1.Severe abdominal pain.
2.Nausea and vomiting.
3.Diarrhea.
B.Common/typical scenario.
1.Patients may start with sudden onset dull pain in the abdomen that becomes increasingly more severe.
2.Pain localizes to the upper abdomen and may radiate to back.
3.Usually associated with nausea and vomiting.
4.Patients usually restless and bending forward to try to alleviate the constant pain.
C.Family and social history.
1.Alcoholism.
2.Familial history of hypertriglyceridemia.
3.Recent abdominal surgery or trauma.
D.Review of systems.
1.Constitutional: Ask about any fever.
2.Cardiovascular: May have rapid heartbeat or feel lightheaded.
3.Respiratory: Ask about any difficulty breathing or trouble getting air in.
4.Gastrointestinal: Ask about nausea, vomiting, diarrhea, pain location and intensity, and if any radiation.
5.Weight loss.
Physical Examination
A.Gastrointestinal—abdominal tenderness, distention, guarding, bowel sounds may be diminished or absent, may have jaundice.
B.Respiratory—dyspnea from diaphragmatic inflammation.
C.Cardiovascular—hemodynamic instability in severe acute pancreatitis; assess for signsand symptoms of shock.
D.Skin—physical findings consistent with severe necrotizing pancreatitis.
1.Cullen sign: Periumbilical bluish discoloration.
2.Grey Turner sign: Reddish brown discoloration along flanks consistent with extravasated pancreatic exudate.
Diagnostic Tests
A.Lab studies.
1.Amylase and lipase are routinely ordered and will be elevated at least 3× above normal reference range in acute pancreatitis. The serum level of amylase or lipase does not correlate with severity.
a.Amylase: Half-life is short (less than 12 hours) and will return to normal; not specific to acute pancreatitis.
b.Lipase elevations support diagnosis of acute pancreatitis and is more specific than amylase to the pancreas.
2.Liver function tests (LFTs).
a.Alkaline phosphatase.
b.Total bilirubin.
c.Aspartate aminotransferase (AST).
d.Alanine aminotransferase (ALT) greater than 150 U/L suggests gallstone pancreatitis.
3.Basic metabolic panel, electrolytes, cholesterol, and triglycerides.
a.Hypertriglyceridemia (greater than 1,000 mg/dL).
4.C-reactive protein.
a.Higher levels (greater than 10 mg/dL) associated with severe pancreatitis, but is not specific for pancreatitis.
5.Lactic dehydrogenase (LDH) should be checked to provide prognosis based on the Ranson criteria (see section “Evaluation and Management Plan“).
6.Immunoglobulin G4 (IgG4) if concern for autoimmune pancreatitis.
B.Imaging studies.
1.Ultrasound.
a.Good screening test for determining the etiology of pancreatitis and standard of care for detecting gallstones.
b.Cannot measure severity of disease.
2.Endoscopic ultrasonography.
a.High frequency ultrasound can provide more detailed imagery.
3.Contrast-enhanced CT or MRI only necessary if a diagnosis is uncertain with clinical presentation and laboratory data.
C.Endoscopic retrograde cholangiopancreatography (ERCP).
1.Endoscopic procedure used in patients with severe acute pancreatitis with suspected gallstones or biliary pancreatitis with worsening clinical examination.
2.Not used routinely in patients with acute pancreatitis and should be used with caution and only in cases where gallstones are suspected to be the underlying etiology.
Differential Diagnosis
A.Cholecystitis.
B.Acute abdomen.
C.Pneumonia.
D.Peptic ulcer disease.
E.Hepatitis.
F.Irritable bowel syndrome.
G.Myocardial infarction.
H.Chronic pancreatitis.
I.Gastroenteritis.
J.Peritonitis.
Evaluation and Management Plan
A.General plan.
1.Stage acute pancreatitis to determine prognosis using the 11-point Ranson criteria within 48 hours. Each criteria is 1 point. Ranson score 0 to 2: Minimal mortality; Ranson score 3 to 5: 10% to 20% mortality; Ranson score greater than 5 after 48 hours has a mortality rate greater than 50%.
a.Present on admission.
i.Patient older than 55 years.
ii.White blood cell (WBC) count higher than 16,000 uL.
iii.Blood glucose higher than 200 mg/dL.
iv.Serum LDH level higher than 350 IU/L.
v.AST level higher than 250 IU/L.
b.Develops within 48 hours.
i.Drop of hematocrit more than 10%.
ii.Blood urea nitrogen (BUN) increases more than 8 mg/dL.
iii.Fluid retention greater than 6 L.
iv.Base deficit greater than 4 mEq/L.
v.PaO2 less than 60 mmHg.
vi.Serum calcium less than 8 mg/dL.
2.Supportive medical care.
a.Bowel rest for several days except in mild cases where there is no nausea or vomiting.
b.Nutritional support with dextrose 5% in water for mild pancreatitis.
c.In moderate to severe pancreatitis, start nasojejunal feeds with low fat formulation.
d.Parenteral nutrition should be avoided except in very severe cases in order to minimize the risk of infections.
e.Pain management.
f.Aggressive rehydration with intravenous fluids within the first 12 to 24 hours of symptom onset—monitor patients with cardiovascular and renal comorbidities very closely.
3.Surgical therapy.
a.ERCP within 24 hours of admission if patient has concurrent acute cholangitis.
b.Gallstones may require surgical intervention.
c.Resection of necrotic tissue if necrotizing pancreatitis or abscess.
d.Sphincteroplasty may be performed if sphincter dysfunction is found.
4.Monitor for complications associated with severe acute pancreatitis.
a.Shock.
b.Pulmonary complications.
c.Inflammatory changes.
i.Kidney dysfunction.
ii.Gastrointestinal bleeding.
iii.Colitis.
iv.Splenic vein thrombosis.
d.Localized complications are more likely to occur in patients with alcoholic and biliary pancreatitis.
i.Fluid collection.
ii.Ascites.
iii.Pseudocysts.
B.Patient/family teaching points.
1.Acute pancreatitis is typically relieved after a couple days but can become severe.
2.Avoid binge drinking.
3.Smoking cessation is thought to exacerbate episodes of acute pancreatitis but the studies are not conclusive.
4.Recurrence of acute pancreatitis may occur and prevention depends on the cause.
a.If gallstones caused acute pancreatitis, you may need to have your gallbladder removed.
b.If alcohol is the cause, you should stop drinking.
5.Diet changes may be required in people with high fat intake.
6.Medication changes may be necessary if acute pancreatitis is associated with a particular drug.
7.Some patients may develop chronic pancreatitis but acute pancreatitis is more frequently a one off event, especially if the underlying cause is treated.
C.Pharmacotherapy.
1.No specific pharmacological therapy for acute pancreatitis.
2.Supportive fluid resuscitation and management of pain.
3.Antibiotic therapy only in cases of suspected infection.
D.Discharge instructions.
1.Eliminate alcohol from diet.
2.Eat small frequent meals.
3.Reduce fat in diet.
4.Don’t smoke.
5.Follow-up with the gastroenterologist.
Follow-Up
A.No guidelines established for long-term follow-up.
B.Depending on etiology, may need follow-up imaging or lab monitoring.
Consultation/Referral
A.Gastroenterology should evaluate all cases of pancreatitis.
B.Surgical consult for acute pancreatitis related to gallstones.
C.Endocrinology consult if patient has hyperparathyroidism, hypertriglyceridemia, or hypercalcemia-induced pancreatitis.
D.Refer patients to social work if alcohol abuse suspected.
Special/Geriatric Considerations
A.Gallstone pancreatitis is much more likely in elderly and pregnant persons.
B.Presenting abdominal pain may be more vague in elderly patients.
C.Acute pancreatitis is rare during pregnancy but typically occurs in the third trimester and is mostly due to gallstones, which can cause preterm labor or in utero fetal demise.
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