pancreatitis

see also:

• chronic pancreatitis;
• general surgery

• alcohol abuse - esp. males 35-45yrs
• cholelithiasis (gallstones) - esp. females > 40yrs
• acute severe hypertriglyceridaemia (SHTG)
• others (<10%):
  • trauma - penetrating or blunt
  • pregnancy - any trimester, post-partum
  • post-ERCP
  • hypercalcaemia
  • penetrating peptic ulcer
  • drugs, toxins - oestrogen, phenformin, steroids, rifampicin, tetracyclines, isoniazid, thiazides, frusemide / furosemide / Lasix, salicylates, indomethacin, warfarin, paracetamol (acetaminophen), ethacrynic acid, glucagon-like peptide-1 (GLP-1) peptide analogs (eg. Ozempic), gabapentinoids
  • obstruction - neoplasms, diverticula, roundworms, benign
  • viral infection - mumps, hep A,B,C, IM, Coxsackie Gp B, Rubella, CMV, EBV, Varicella, Echo, Adenovirus
  • bacterial infection - typhoid, paratyphoid, scarlet fever, strept. food poisoning, dysentery, TB, mycoplasma, MAIS, legionella, leptospirosis, campylobacter
  • other infection - ascariasis, clonorchiasis
  • CT disease - systemic lupus erythematosus (SLE), polyarteritis nodosa
  • cystic fibrosis
  • aortic dissection

• mid-epigastric or LUQ pain:
  • usually constant, boring, often radiates to back as well as flanks, chest or lower abdomen
  • variable intensity
  • worse supine & relieved by sitting with trunk & knees flexed
• nausea & vomiting are common
• abdominal bloating due to GIT hypomotility frequent
• examination:
  • epigastric tenderness
  • may have low grade fevers, tachycardia, and hypotension
  • 10% have resp. symptoms due to atelectasis, pleural effusion (usually left sided) & rarely, ARDS
  • peritonitis is a late finding
  • rarely, haemorrhagic pancreatitis occurs which may cause Cullen sign & Grey Turner sign as bruising tracks to flanks & around umbilicus.
  • hypotension may result from fluid third-spacing, increased vascular permeability, vasodilatation, cardiac depression & vomiting.

• serum lipase rise early & are reasonably sensitive (90%) but not totally specific (75% for amylase, 90% for lipase)
• erect CXR, AXR useful to exclude other pathology such as perforated viscus & may show a pleural effusion
  • calcification suggests chronic pancreatitis
• biliary US may show cholelithiasis (gallstones), pancreatic oedema & pseudocysts, but is insensitive in Dx of acute pancreatitis
• CT abdomen is insensitive in early or mild disease

• Ranson criteria for predicting mortality risk from acute pancreatitis:
  • on admission:
    • age > 55yrs
    • blood sugar > 11mM
    • WCC > 16,000
    • AST > 250
    • LDH > 400
  • 48hrs later:
    • haematocrit fall > 10%
    • BUN rise > 1.8mM
    • fall in Ca to < 1.9mM
    • fall in PaO2 below 60mmHg 
    • rapid fluid sequestration > 6L
    • base deficit > 4 meq/L
• criteria interpretation:
  • < 3 markers = <1% mortality
  • 3-4 markers = 16% mortality
  • 5-6 markers = 40% mortality
  • 6 markers = 100% mortality
• MDCalc.com's Ranson criteria calculator

• 90% recover with supportive care of “resting” the pancreas:
  • nil oral or clear fluids (some advocate NG tube but no evidence to support benefit)
  • IV fluid resuscitation to ensure urine output 100ml/h
  • unstable patients may require invasive monitoring
  • parenteral narcotics & antiemetics
  • if severe, IV imipenem decreases sepsis rate but not mortality
• in biliary pancreatitis:
  • urgent decompression is indicated if there is persistent biliary obstruction
  • transient obstruction only, then elective cholecystectomy once inflammation subsides
• see acute severe hypertriglyceridaemia (SHTG) for emergent Mx of this cause including possible plasmapheresis
• acute fluid collections are rarely symptomatic & frequently resolve spontaneously
• laparatomy is indicated for haemorrhage control & abscess drainage

• home if:
  • mild alcoholic pancreatitis with no evidence of systemic complications and,
  • able to tolerate oral fluids, and,
  • pain is well controlled
  • follow up in 24-48hrs
• otherwise, admit under general surgery unit.
• ALL patients with pancreatitis due to biliary causes should be admitted.
• high risk patients should be admitted to a hospital with ICU capabilities
• NB. a 2024 study suggests ~1/3rd of patients will develop exocrine pancreas insufficiency (EPI) by 12 months as assessed by measuring fecal elastase 1 (FE-1) levels ¹⁾