Diagnosis
H&P:
Risk Factors:
DDx and common causes, reviewed.
Studies: Lipase (which is more specific than amylase).
Imaging: CT abd. w/ contrast or U/S of abd; KUB/CXR
Category: Interstitial edematous vs. necrotizing acute pancreatitis (which type is it?)
Severity: Mild, moderate, and severe acute pancreatitis (what is the severity?).
Diagnostic criteria, classification, and severity reviewed.
Assess severity using the SIRS score or APACHE II score.
Will watch for complications like 1) acute peripancreatic fluid collection, 2) pancreatic pseudocyst, 3) acute necrotic collection, and walled-off necrosis (infected necrosis/sterile necrosis), 5) Splanchnic venous thrombosis, 6) pseudoaneurysm, 7) abd. compartment syndrome, and 8) systemic complications.
Treatment
Tx is supportive therapy, bowel rest, fluid replacement, pain control, and nutrition.
Fluid resuscitation: LR or NS at 5 to 10 mL/kg/h [or to keep UOP ≥ 0.5 mL/kg/h] if no CV, renal, or other contraindications. If pancreatitis is caused by hypercalcemia, will not use LR since it has 3 mEq/L calcium. If pt is severely volume depleted, will give 20 mL/kg of IVF bolus over 30 minutes followed by 3 mL/kg/h for 8 to 12 hours.
Pain Control: Ensure adequate fluid replacement to control pain. Morphine for pain. If necessary, may use hydromorphone. The theoretical risk of Sphincter of Oddi spasm by opiates hasn’t been shown to adversely affect outcomes. If that is the case in this patient, would use IV meperidine.
Antinausea: Zofran
GI prophylaxis: Protonix 40 IV BID
Nutrition: If there is no ileus, sig. nausea or vomiting, and if the pain is decreasing and inflammatory markers are improving, I will start oral feeding early (within 24 hours) as tolerated. Start with a low residue, low fat, soft diet. Advance the diet cautiously as tolerated.
-Start enteral nutrition in pts with a mod to severe AP if they cannot tolerate oral diet by day five.
-If this were severe pancreatitis and NPO > 7 days is expected, early (within 48h) enteral nutrition would be indicated and preferred over TPN because that would decrease infectious complications. In that case, NJ tube would be preferred, but NG tube will be okay.
F/u UDS
F/u Lipid Panel (Elevated TG cause pancreatitis)
DVT prophylaxis: Enoxaparin
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Three Types of nutrition: 1) Oral (pt eats normally through the mouth; 2) Enteral (NG tube, NJ, or G-tube is used), and 3) Parenteral ( e.g. TPN or tube feeds). Note that the para- in parenteral means beyond. Think of the French word pas. Parenteral = not enteral or not through the intestines.
For pts with severe acute pancreatitis, get a “contrast-enhanced CT based upon clinical criteria or possibly the APACHE II score to determine if necrotizing pancreatitis is present.”
” Although measurement of serum amylase and lipase is useful for diagnosis of pancreatitis, serial measurements in patients with acute pancreatitis are not useful to predict disease severity, prognosis, or for altering management.”
“Transabdominal ultrasound should be performed in all patients with acute pancreatitis (strong recommendation, low quality of evidence).” ACG 2013.
Acute Pancreatitis Pearls and Links
“Nutrition in Acute Pancreatitis (AP).
Recommendations from the ACG
- In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and the abdominal pain has resolved (conditional recommendation, moderate quality of evidence).
- In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet (conditional recommendations, moderate quality of evidence).
- In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided, unless the enteral route is not available, not tolerated, or not meeting caloric requirements (strong recommendation, high quality of evidence).
- Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety (strong recommendation, moderate quality of evidence).” ACG 2013.
“Continuous enteral nutrition feeding is preferred over bolus feeding. A meta-analysis has shown that continuous nasogastric enteral feeding started in the first 48 hours decreases mortality and the length of hospital stay.”
“Historically, patients with acute pancreatitis were kept NPO to rest the pancreas. Evidence now shows that bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut. Multiple studies have shown that patients who are provided oral feeding early in the course of acute pancreatitis have a shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality. Starting with a low-fat solid diet has been shown to be safe compared with clear liquids, providing more calories and shortening hospital stays.
Total parenteral nutrition should be avoided in patients with mild or severe acute pancreatitis. There have been multiple randomized trials showing that total parenteral nutrition is associated with infectious and other line-related complications.” ABFM
Reference
Am J Gastroenterol 2013; 108:1400–1415. https://gi.org/guideline/acute-pancreatitis