Pancreatitis - Clinicals, Diagnosis, and Management

Hepato-Pancreatico-Biliary

Clinicals - History

Fact Explanation
Pattern of presentation Acute pancreatitis, inflammation of the pancreatic parenchyma is a common cause of emergency admission with acute abdomen. There is premature activation of pancreatic enzymes within the pancreatic ducts resulting auto-digestion of the gland. The initial cellular injury is followed by an inflammatory reaction. Patient presentation varies according to the severity which ranges from mild to severe. Pattern of presentation
Acute pancreatitis, inflammation of the pancreatic parenchyma is a common cause of emergency admission with acute abdomen. There is premature activation of pancreatic enzymes within the pancreatic ducts resulting auto-digestion of the gland. The initial cellular injury is followed by an inflammatory reaction. Patient presentation varies according to the severity which ranges from mild to severe.
Abdominal pain Abdominal pain is a cardinal symptom of acute pancreatitis. The pain is acute in onset, severe and reaches a peak within minutes. Pain is usually felt in the epigastric region and characteristically radiates to the back. The patient experiences comfort when bending or leaning forwards. Abdominal pain
Abdominal pain is a cardinal symptom of acute pancreatitis. The pain is acute in onset, severe and reaches a peak within minutes. Pain is usually felt in the epigastric region and characteristically radiates to the back. The patient experiences comfort when bending or leaning forwards.
Nausea and vomiting Nausea and vomiting is a constant feature of pancreatitis. Nausea and vomiting
Nausea and vomiting is a constant feature of pancreatitis.
Fever Fever is not a common symptom of acute pancreatitis. Swinging pyrexia with rigors may be due to acute cholangitis. Fever
Fever is not a common symptom of acute pancreatitis. Swinging pyrexia with rigors may be due to acute cholangitis.
Anorexia Due to the systemic inflammatory response. Anorexia
Due to the systemic inflammatory response.
Presentation with localized complications Common local complications include pancreatic necrosis with secondary infection, pancreatic abscess, pseudocyst formation and pseudoaneurysm. The onset is usually after the acute attack and carries an increased morbidity and mortality. Pancreatic pseudocysts develop 4 weeks after the acute attack and present with abdominal pain and epigastric mass. Abscess formation and secondary infection present with fever, abdominal pain and tender abdominal mass following recovery of initial attack. Presentation with localized complications
Common local complications include pancreatic necrosis with secondary infection, pancreatic abscess, pseudocyst formation and pseudoaneurysm. The onset is usually after the acute attack and carries an increased morbidity and mortality. Pancreatic pseudocysts develop 4 weeks after the acute attack and present with abdominal pain and epigastric mass. Abscess formation and secondary infection present with fever, abdominal pain and tender abdominal mass following recovery of initial attack.
Presentation with systemic complications Acute pancreatitis is known cause of systemic inflammatory response syndrome (SIRS). Chemical mediators generated as part of the inflammatory reaction within the pancreas are released into the circulation. The resulting systemic inflammatory response may lead to multiple organ failure. Patients with severe acute pancreatitis may present with acute renal failure, disseminated intravascular coagulation, acute lung injury, haemodynamic instability etc. Presentation with systemic complications
Acute pancreatitis is known cause of systemic inflammatory response syndrome (SIRS). Chemical mediators generated as part of the inflammatory reaction within the pancreas are released into the circulation. The resulting systemic inflammatory response may lead to multiple organ failure. Patients with severe acute pancreatitis may present with acute renal failure, disseminated intravascular coagulation, acute lung injury, haemodynamic instability etc.
Risk factors/ Aetiology The two most important causes of acute pancreatitis are alcohol consumption and gallstone disease. The pathogenesis of alcohol induced pancreatitis is multi-factorial - Direct pancreatic injury, poor nutrition, hypersecretion of pancreatic enzymes and hyperlipidaemia. Gallstones located within the gallbladder or bile ducts may pass downwards and get obstructed at the common bile and pancreatic duct opening. The patient may complain of a past history of chronic upper abdominal pain, dyspeptic symptoms and fatty food intolerance. Evaluate the current drugs the patient is on, corticosteroids, sodium valproate, azathioprine and oestrogens may precipitate an attack. Abdominal trauma, surgery, ERCP may rarely be the cause. A positive family history for pancreatitis may suggest hereditary pancreatitis or auto-immune pancreatitis. Risk factors/ Aetiology
The two most important causes of acute pancreatitis are alcohol consumption and gallstone disease. The pathogenesis of alcohol induced pancreatitis is multi-factorial - Direct pancreatic injury, poor nutrition, hypersecretion of pancreatic enzymes and hyperlipidaemia. Gallstones located within the gallbladder or bile ducts may pass downwards and get obstructed at the common bile and pancreatic duct opening. The patient may complain of a past history of chronic upper abdominal pain, dyspeptic symptoms and fatty food intolerance. Evaluate the current drugs the patient is on, corticosteroids, sodium valproate, azathioprine and oestrogens may precipitate an attack. Abdominal trauma, surgery, ERCP may rarely be the cause. A positive family history for pancreatitis may suggest hereditary pancreatitis or auto-immune pancreatitis.

Clinicals - Examination

Fact Explanation
General examination : Reduced conscious level Confusion may be multi-factorial. Metabolic derangement, hypovolaemic shock, toxiaemia and hypoxaemia may contribute to central nervous system dysfunction. General examination : Reduced conscious level
Confusion may be multi-factorial. Metabolic derangement, hypovolaemic shock, toxiaemia and hypoxaemia may contribute to central nervous system dysfunction.
General examination : Fever Fever is rare in the early stages but may develop with time. Infection of the necrotic pancreas and acute cholangitis may present with fever. Some patients may experience hypothermia in the initial stages. General examination : Fever
Fever is rare in the early stages but may develop with time. Infection of the necrotic pancreas and acute cholangitis may present with fever. Some patients may experience hypothermia in the initial stages.
General examination : Icterus In gallstone pancreatitis bile flow may be obstructed by the presence of a stone at the ampulla. General examination : Icterus
In gallstone pancreatitis bile flow may be obstructed by the presence of a stone at the ampulla.
General examination : Features of dehydration Due to poor intake and fluid loss. The mucous membranes and skin appears dry. The eyes may be sunken. Skin elasticity is reduced. The capillary refill time will be prolonged. General examination : Features of dehydration
Due to poor intake and fluid loss. The mucous membranes and skin appears dry. The eyes may be sunken. Skin elasticity is reduced. The capillary refill time will be prolonged.
General examination : Hemorrhage into the skin layers In severe hemorrhagic acute pancreatitis there may be bleeding into the fascial planes of the abdomen. Presence of a hematoma in the flank region (Grey Turner’s sign) and surrounding the umbilicus (Cullen’s sign) are rare features. General examination : Hemorrhage into the skin layers
In severe hemorrhagic acute pancreatitis there may be bleeding into the fascial planes of the abdomen. Presence of a hematoma in the flank region (Grey Turner’s sign) and surrounding the umbilicus (Cullen’s sign) are rare features.
Skin nodules on the abdomen and lower limbs Due to fat necrosis. Pancreatic lipase released as a result of pancreatitis leads to auto-digestion of fat tissues of the skin and subcutaneous tissue. The nodules are small tender and erythematous. Skin nodules on the abdomen and lower limbs
Due to fat necrosis. Pancreatic lipase released as a result of pancreatitis leads to auto-digestion of fat tissues of the skin and subcutaneous tissue. The nodules are small tender and erythematous.
Cardiovascular system : Hypotension and tachycardia Features of severe acute pancreatitis. Cardiovascular system : Hypotension and tachycardia
Features of severe acute pancreatitis.
Abdominal examination – Tenderness in the epigastrium Due to the underlying inflamed pancreas. Guarding will be present due to contraction of the overlying abdominal wall muscles. Abdominal examination – Tenderness in the epigastrium
Due to the underlying inflamed pancreas. Guarding will be present due to contraction of the overlying abdominal wall muscles.
Abdominal examination : Distension Due to intestinal ileus. Abdominal examination : Distension
Due to intestinal ileus.
Abdominal examination : Epigastric mass An inflammatory mass may be palpable in the epigastium. It would be tender, with diffuse margins and may be difficult to further define due to tenderness within the region. Abdominal examination : Epigastric mass
An inflammatory mass may be palpable in the epigastium. It would be tender, with diffuse margins and may be difficult to further define due to tenderness within the region.

Investigations - Diagnosis

Fact Explanation
Diagnosis of acute pancreatitis Diagnosis is often based on clinical presentation which is confirmed by laboratory investigations. Further investigations are required to determine the severity, identify the aetiology and exclude any complications. Diagnosis of acute pancreatitis
Diagnosis is often based on clinical presentation which is confirmed by laboratory investigations. Further investigations are required to determine the severity, identify the aetiology and exclude any complications.
Serum amylase A three to four fold rise in the serum amylase levels is diagnostic of acute pancreatitis. Serum amylase
A three to four fold rise in the serum amylase levels is diagnostic of acute pancreatitis.
Serum lipase Elevation of lipase levels lasts longer than amylase levels. It can be used in patients who present late, 2-4 days after the acute attack. Serum lipase is considered a more sensitive and specific investigation than serum amylase. Serum lipase
Elevation of lipase levels lasts longer than amylase levels. It can be used in patients who present late, 2-4 days after the acute attack. Serum lipase is considered a more sensitive and specific investigation than serum amylase.
Ultrasound scan – Abdomen Apart from edema around the pancreas USS does not show other specific features for diagnosing acute pancreatitis. Gallstones within the biliary system and dilatation of the proximal bile duct help establish the aetiology for pancreatitis. It can be used to exclude other differential diagnosis such as acute cholecystitis and acute appendicitis. Ultrasound scan – Abdomen
Apart from edema around the pancreas USS does not show other specific features for diagnosing acute pancreatitis. Gallstones within the biliary system and dilatation of the proximal bile duct help establish the aetiology for pancreatitis. It can be used to exclude other differential diagnosis such as acute cholecystitis and acute appendicitis.
Contrast-enhanced CT This is considered the single best imaging modality for diagnosis of acute pancreatitis. Necrosis of pancreatic tissue, edema of surrounding tissue and fat necrosis can be identified by CT scan. The severity of the attack can be assessed and can be staged according to the Balthazar criteria. The grade of pancreatitis and the extent of pancreatic necrosis are assessed in this criteria. The accuracy of determining the severity of the attack by this method is considered higher than in Ranson and APACHE 2 score. Local complications such as pseudocyst formation, pseudoaneurysm and pancreatic abscess can be screened for. Contrast-enhanced CT
This is considered the single best imaging modality for diagnosis of acute pancreatitis. Necrosis of pancreatic tissue, edema of surrounding tissue and fat necrosis can be identified by CT scan. The severity of the attack can be assessed and can be staged according to the Balthazar criteria. The grade of pancreatitis and the extent of pancreatic necrosis are assessed in this criteria. The accuracy of determining the severity of the attack by this method is considered higher than in Ranson and APACHE 2 score. Local complications such as pseudocyst formation, pseudoaneurysm and pancreatic abscess can be screened for.
Magnetic resonance imaging (MRI) Even though MRI can be used instead of CT to obtain similar results, the lack of facilities and availability limits its use. Magnetic resonance imaging (MRI)
Even though MRI can be used instead of CT to obtain similar results, the lack of facilities and availability limits its use.
Abdominal X-ray Plain radiography has limited value as a diagnostic test. Calcified gallstones can be identified near the region of the ampulla. Calcification within the pancreatitis may indicate a hereditary type of pancreatitis. Presence of hemoperitoneum can be used to differentiate perforated peptic ulcer. Abdominal X-ray
Plain radiography has limited value as a diagnostic test. Calcified gallstones can be identified near the region of the ampulla. Calcification within the pancreatitis may indicate a hereditary type of pancreatitis. Presence of hemoperitoneum can be used to differentiate perforated peptic ulcer.
ERCP/ EUS These investigations can be used to exclude the presence of gallstones at the ampulla. ERCP can be used as a therapeutic option to remove the obstruction gallstone by sphincterotomy. Patients with biliary obstruction and acute cholangitis require urgent ERCP. ERCP/ EUS
These investigations can be used to exclude the presence of gallstones at the ampulla. ERCP can be used as a therapeutic option to remove the obstruction gallstone by sphincterotomy. Patients with biliary obstruction and acute cholangitis require urgent ERCP.

Investigations - Management

Fact Explanation
Full blood count To screen for secondary infection. White blood cell count is also used in determining the severity. Full blood count
To screen for secondary infection. White blood cell count is also used in determining the severity.
Blood urea, Serum creatinine To assess renal functions. Blood urea, Serum creatinine
To assess renal functions.
Serum electrolytes Electrolyte imbalances are common among patients with severe acute pancreatitis. Serum calcium less than 2.0mmol l–1 is suggestive of severe pancreatitis. Serum electrolytes
Electrolyte imbalances are common among patients with severe acute pancreatitis. Serum calcium less than 2.0mmol l–1 is suggestive of severe pancreatitis.
Liver function tests : AST/ALT/Serum albumin To screen for disturbances in hepatic function. Liver function tests : AST/ALT/Serum albumin
To screen for disturbances in hepatic function.
Arterial blood gas To identify acid-base and electrolyte imbalances. Respiratory failure may be present in severe acute pancreatitis. Arterial blood gas
To identify acid-base and electrolyte imbalances. Respiratory failure may be present in severe acute pancreatitis.
Blood glucose level To screen for hyper/ hypoglycaemia. Blood glucose level
To screen for hyper/ hypoglycaemia.
Severity stratification Severity stratification is important to identify patients presenting with severe acute pancreatitis who are at higher risk of developing complications. Various scoring systems are used for this purpose. Ranson score, Glasgow score and the APACHE II scoring system can be used. Both the Ranson and Glasgow score assess parameters both at presentation and after 48 hours. As per Ranson score - Age more than 55yr, White blood cell count > 16*109, Blood glucose > 10 mmol l–1, LDH > 700 units l–1 & AST > 250 at admission and arterial oxygen saturation < 8 kPa, Serum calcium < 2.0 mmol l–1, Base deficit > 4mmol l–1, Fluid sequestration > 6 litres and Blood urea nitrogen rise > 5 mg% after 48h is considered severe acute pancreatitis. Ranson score is considered an accurate measure of the severity compared to APACHE 2 and the more recent APACHE 3 score. Severity stratification
Severity stratification is important to identify patients presenting with severe acute pancreatitis who are at higher risk of developing complications. Various scoring systems are used for this purpose. Ranson score, Glasgow score and the APACHE II scoring system can be used. Both the Ranson and Glasgow score assess parameters both at presentation and after 48 hours. As per Ranson score - Age more than 55yr, White blood cell count > 16*109, Blood glucose > 10 mmol l–1, LDH > 700 units l–1 & AST > 250 at admission and arterial oxygen saturation < 8 kPa, Serum calcium < 2.0 mmol l–1, Base deficit > 4mmol l–1, Fluid sequestration > 6 litres and Blood urea nitrogen rise > 5 mg% after 48h is considered severe acute pancreatitis. Ranson score is considered an accurate measure of the severity compared to APACHE 2 and the more recent APACHE 3 score.
Chest X-ray Pleural effusions and features of acute respiratory distress syndrome may be seen in severe acute pancreatitis. Chest X-ray
Pleural effusions and features of acute respiratory distress syndrome may be seen in severe acute pancreatitis.
Clotting profile To identify coagulations abnormalities in systemic disease. Clotting profile
To identify coagulations abnormalities in systemic disease.

Management - Specific

Fact Explanation
Management of acute pancreatitis There is no specific treatment for acute pancreatitis patients. Management consists of symptomatic relief, monitoring and management of complications. Patients presenting with mild acute pancreatitis can be conservatively managed with observation and symptomatic treatment (fluid management & analgesia) alone. Management of severe acute pancreatitis requires more intense monitoring and aggressive fluid resuscitation, pain relief, anti-emetic therapy, nutritional support and prophylaxis antibiotics. If a definitive cause such as gallstone disease is identified specific treatment options can be taken. Management of acute pancreatitis
There is no specific treatment for acute pancreatitis patients. Management consists of symptomatic relief, monitoring and management of complications. Patients presenting with mild acute pancreatitis can be conservatively managed with observation and symptomatic treatment (fluid management & analgesia) alone. Management of severe acute pancreatitis requires more intense monitoring and aggressive fluid resuscitation, pain relief, anti-emetic therapy, nutritional support and prophylaxis antibiotics. If a definitive cause such as gallstone disease is identified specific treatment options can be taken.
Management setting Patients with mild pancreatitis can be managed in the ward setting. Patients with features of severe pancreatitis as predicted by scoring systems require admission to an intensive care unit or high dependency unit. Management setting
Patients with mild pancreatitis can be managed in the ward setting. Patients with features of severe pancreatitis as predicted by scoring systems require admission to an intensive care unit or high dependency unit.
Oxygen supplementation Monitor arterial blood saturation. Oxygen is administered if failure for adequate saturation is present. Respiratory support via ventilation may be required if acute respiratory distress syndrome develops. Oxygen supplementation
Monitor arterial blood saturation. Oxygen is administered if failure for adequate saturation is present. Respiratory support via ventilation may be required if acute respiratory distress syndrome develops.
Analgesics For pain relief. Analgesics should be administered according to the analgesic ladder introduced by the WHO. Certain opioids such as morphine are avoided due to the risk of pancreatic duct constriction and further deterioration. Pethidine is preferred in these patients. Analgesics
For pain relief. Analgesics should be administered according to the analgesic ladder introduced by the WHO. Certain opioids such as morphine are avoided due to the risk of pancreatic duct constriction and further deterioration. Pethidine is preferred in these patients.
Anti-emetic drugs For relief of nausea and vomiting. Anti-emetic drugs
For relief of nausea and vomiting.
Fluid management Monitor fluid intake and output. Fluid resuscitation should be guided by cardiovascular parameters, urine output and central venous pressure. Pancreatic ascites is due to a persistent leak via an opened up pancreatic duct. These patients may present with abdominal distention and shock. Manage hypovolaemic shock with intravenous crystolloids and colloids. Fluid management
Monitor fluid intake and output. Fluid resuscitation should be guided by cardiovascular parameters, urine output and central venous pressure. Pancreatic ascites is due to a persistent leak via an opened up pancreatic duct. These patients may present with abdominal distention and shock. Manage hypovolaemic shock with intravenous crystolloids and colloids.
Nutrition Enteral nutrition is preferred to parenteral nutrition in severe acute pancreatitis. A nasogastric tube can be used for gastric emptying in the acute setting and can also be used as a feeding method. Avoid prolonged fasting. Nutrition
Enteral nutrition is preferred to parenteral nutrition in severe acute pancreatitis. A nasogastric tube can be used for gastric emptying in the acute setting and can also be used as a feeding method. Avoid prolonged fasting.
Prophylactic antibiotics Intravenous antibiotics can be used in severe pancreatitis to reduce the risk of infective complications. Combination of antibiotics to provide broad spectrum cover – Cefuroxime, metronidazole and ciprofloxacin is used. Mild attacks of pancreatitis usually do not require prophylactic antibiotics. Prophylactic antibiotics
Intravenous antibiotics can be used in severe pancreatitis to reduce the risk of infective complications. Combination of antibiotics to provide broad spectrum cover – Cefuroxime, metronidazole and ciprofloxacin is used. Mild attacks of pancreatitis usually do not require prophylactic antibiotics.
Management of gallstone pancreatitis If gallstone disease is suspected by the presence of jaundice, cholangitis or a previous history of gallstone related symptoms, these patients require urgent ERCP to remove the obstructing stone by sphincterotomy. Imaging with EUS, MRCP can be used visualize the biliary tree. Dilatation of the common bile duct is a feature of gallstone pancreatitis. Further evaluation is required to determine the suitable time for ERCP intervension in these patients. Management of gallstone pancreatitis
If gallstone disease is suspected by the presence of jaundice, cholangitis or a previous history of gallstone related symptoms, these patients require urgent ERCP to remove the obstructing stone by sphincterotomy. Imaging with EUS, MRCP can be used visualize the biliary tree. Dilatation of the common bile duct is a feature of gallstone pancreatitis. Further evaluation is required to determine the suitable time for ERCP intervension in these patients.
Management of organ failure These patients require management within an intensive care unit. Acute respiratory distress syndrome requires intubation and ventilation. Hemodynamic instability is managed with intravenous fluids initially with the support of inotropes. DIC is managed with conservatively with blood product transfusion. Acute renal failure is managed with correction of electrolyte imbalances and fluid management. Management of organ failure
These patients require management within an intensive care unit. Acute respiratory distress syndrome requires intubation and ventilation. Hemodynamic instability is managed with intravenous fluids initially with the support of inotropes. DIC is managed with conservatively with blood product transfusion. Acute renal failure is managed with correction of electrolyte imbalances and fluid management.
Management of local complications In most instances these are managed conservatively while surgery is reserved for resistant patients. Repeat CT scan is required if the patient worsens after recovery of the acute attack. Pancreatic abscesses are drained under antibiotic cover. Percutaneous drainage with image guidance is preferred. Open drainage is needed if the above mentioned methods fail. Pancreatic pseudocysts can be managed by endoscopic and surgical measures. Endoscopic drainage of the cyst into the stomach or duodenum is the preferred option. Endoscopic ultrasound is used to puncture the cyst through the stomach or duodenum and a draining tube is placed in situ. Surgical drainage is used if endoscopic methods fail or if the cyst is complicated. Percutaneous drainage is avoided. Management of local complications
In most instances these are managed conservatively while surgery is reserved for resistant patients. Repeat CT scan is required if the patient worsens after recovery of the acute attack. Pancreatic abscesses are drained under antibiotic cover. Percutaneous drainage with image guidance is preferred. Open drainage is needed if the above mentioned methods fail. Pancreatic pseudocysts can be managed by endoscopic and surgical measures. Endoscopic drainage of the cyst into the stomach or duodenum is the preferred option. Endoscopic ultrasound is used to puncture the cyst through the stomach or duodenum and a draining tube is placed in situ. Surgical drainage is used if endoscopic methods fail or if the cyst is complicated. Percutaneous drainage is avoided.

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