Written by Clay Smith
Spoon Feed
Acute pancreatitis is a common ED complaint. This will help you manage it well.
Why does this matter?
Pancreatitis is the most common GI illness that leads to admission. We see it a lot and need a refresher on the latest evidence. Here it is.
Eat when you can; sleep when you can; and don’t mess with the pancreas.
Causes
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The top two are gallstone pancreatitis and alcohol use. Also common are hypercalcemia and hypertriglyceridemia.
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Less common cause are ERCP, autoimmune, structural, hereditary, and a host of medications.
Presentation/Diagnosis/Definition
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Epigastric pain radiating to the back is common, worse with eating, drinking, or lying supine.
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Get a CBC, CMP, lipase, +/- amylase. Ensure your chem panel includes calcium, and check triglycerides. Get a biliary ultrasound if stones are suspected.
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To make the diagnosis, you must have 2 out of 3: 1) a consistent clinical picture of abdominal pain; 2) amylase or lipase > 3x upper limit of normal; or 3) CT evidence of pancreatitis.
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Disease severity ranges from mild pancreatic edema to necrotizing pancreatitis, which may become infected and cause severe, critical illness and sepsis. Patients with SIRS should probably have a CT in the ED and may need antibiotics.
Risk stratification
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The best and simplest is the BISAP score.
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Ranson and APACHE II are a bit cumbersome.
Management
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Early volume repletion with LR is best.
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Early enteral nutrition within 24 hours of admission is favored over parenteral nutrition and decreases mortality and multi-organ failure. Use a low fat, soft diet.
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If unable to tolerate food, tube feeding should be started. If that is not tolerated, start TPN as a last resort.
Follow up
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If gallstones are the culprit, it is best to do the cholecystectomy sooner rather than later, preferably within 24-48 hours of admission if possible.
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Alcohol cessation is key. Many patients need help and resources.
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Triglyceride lowering helps patients with this as the cause.
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Patients with even a first bout may face recurrence, exocrine pancreatic malabsorption, endocrine pancreatic insufficiency, or fluid collections (pseudocysts).
Source
Acute Pancreatitis: A Review. JAMA. 2021 Jan 26;325(4):382-390. doi: 10.1001/jama.2020.20317.
