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Activation of pancreatic enzymes leads to severe abdominal pain → abrupt onset, often accompanied by nausea, vomiting, fever

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  • Pancreatic enzymes activate within the pancreas (vs duodenum) auto-digesting the pancreas → pain & inflammation
  • Common triggers: gallstones/biliary disease (♀ > ♂), alcohol (♂ > ♀), drugs, infection, hypertriglyceridemia

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Signs/symptoms: result of inflammatory response to pancreatic inflammation

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  • Symptoms: epigastric pain (↑ after eating) may radiate to back; nausea, vomiting, & fever common
  • Signs: abdomen tender & distended ± guarding, tachycardia, hypovolemia, hypotension (may progress to shock), jaundice, acute kidney injury (prerenal)
  • Labs: amylase & lipase may ↑ ≥3 × ULN, lipase > sensitivity/specificity; may have ↑ WBC, ALT, bilirubin, LDH & CRP
  • Severity scoring
    • Severe disease may progress to necrosis (sterile or infected), systemic inflammatory response syndrome, acute respiratory distress syndrome, renal failure, multiple organ dysfunction syndrome & death
    Table Graphic Jump Location
    Table 11-1 Ranson's Criteria (Am J Gastroenterol 1982;77:633)

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Table Graphic Jump Location
Table 11-1 Ranson's Criteria (Am J Gastroenterol 1982;77:633)
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Initial treatment: supportive; fluids, gut rest, & analgesia

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  • Fluids: maintain intravascular volume; patients often present with hypovolemia from prolonged NPO/vomiting
  • Nutrition: NPO until pain free with + bowel sounds; enteral refeeding preferred over parenteral
    • Early initiation of nutrition preferred after NPO period
    • Patients with mild disease randomized to soft, low-fat diet had 2d ↓ LOS vs clear-liquid diet (Aliment Pharmacol Ther 2008;28:777)
    • Nasojejunum tube feeds traditionally preferred over nasogastric feeding to ↓ potential stimulation of the pancreas, but strong RCTs are lacking
  • Pain: opiate analgesics usually required
  • Antibiotics: infection from translocation of gut flora; risk of infection correlates to degree of necrosis; infection ↑ risk of organ failure (Br J Surg 1999;86:1020); infection is driving factor in the majority of deaths from severe pancreatitis (Curr Opin Crit Care 2007;13:416)
    • Prophylactic antibiotic use in necrotic pancreatitis has evolved—early uncontrolled studies using prophylactic ABX showed ↓ infection & mortality; current randomized, double-blind, placebo controlled trials do not support ABX without proven infection (Ann Surg 2007;245:674; Gastroenterology 2004;126:997; J Gastrointest Surg 2009;13:768); indiscriminate use of broad-spectrum agents increases the incidence of fungal & drug-resistant bacterial infections (Arch Surg 2001;136:592)
    • Infection: fine-needle aspiration of necrotic tissue needed for culture
      • Empiric antibiotics
        • Must penetrate necrotic pancreas, cover gram-positive, negative, & anaerobic ...

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