Acute Pancreatitis – Spoon-Feed Version

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

  • The top two are gallstone pancreatitis and alcohol use. Also common are hypercalcemia and hypertriglyceridemia.

  • Less common cause are ERCP, autoimmune, structural, hereditary, and a host of medications.

Presentation/Diagnosis/Definition

  • Epigastric pain radiating to the back is common, worse with eating, drinking, or lying supine.

  • Get a CBC, CMP, lipase, +/- amylase. Ensure your chem panel includes calcium, and check triglycerides. Get a biliary ultrasound if stones are suspected.

  • 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.

  • 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

  • The best and simplest is the BISAP score.

  • Ranson and APACHE II are a bit cumbersome.

Management

  • Early volume repletion with LR is best.

  • 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.

  • If unable to tolerate food, tube feeding should be started. If that is not tolerated, start TPN as a last resort.

Follow up

  • 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.

  • Alcohol cessation is key. Many patients need help and resources.

  • Triglyceride lowering helps patients with this as the cause.

  • 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.

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