Atlanta criteria 2012 revision: Mild - Acute inflammation of the pancreas with oedema and resolves without complications Moderate - when the is transient organ failure (<48h) that resolves. Severe - Acute inflammation of the pancreas with necrosis and develops complications, including persistent organ failure (>48h). Diagnosis requires 2 out of 3 of:
Elevated enzymes (amylase or lipase
Radiological findings of pancreatitis
The pancreas is an endocrine and exocrine gland. In regards to its exocrine function, it usually produces and secretes proteases, amylases and lipases into the ducts which are then released into the duodenum. An initial inflammatory trigger can lead to disruption of the normal excretory process, with such enzymes resulting in ‘autodigestion’. This further pancreatic injury can propagate an inflammatory process and injury.
As well as local consequences, there may be a notable systematic response to the inflammation. This can then result in the multisystem effects of pancreatitis, including the multi-organ failure seen in severe disease.
GET SMASHED is the mnemonic often used Gallstones Ethanol Trauma Steroids Mumps (and other viruses) Autoimmune (SLE, pregnancy) Scorpion venom Hypers - hypercalcaemia, hyperlipidaemia, hypothermia, hypotension ERCP Drugs - sulfasalazine, azathioprine, NSAIDs, diuretics, metronidazole, ranitidine, valproate, erythromycin, tetracyclines
Gallstone disease is the most common cause. Alcohol is often the cause associated with the worst outcome. Idiopathic is also a possible outcome - remember Dublin study though (high rate of gallstone disease on close examination)
May present in a few ways:
Appropriate history and >3x normal lipase (amylase)
Unexpected finding on CT
Trauma - cyclist vs handlebars
Severe upper abdo pain
Epigastric. Can be RUQ or LUQ
Usually fairly rapid onset, steadily increasing to peak
Band like radiation into back
Nausea and vomiting
Fevers and chills
Examination Very variable - very well to severely ill
Features of retroperitoneal haemorrhage
Grey-Turner sign - flank ecchymosis
Cullen sign - periumbilical ecchymosis
Amylase (x3 time normal)
Lipase - more specific, longer half life
FBC - raised WBC
U&E - renal dysfunction
LFTS - raised
LDH - part of Ranson’s criteria
CT - contrast enhance
May diagnose in cases of uncertainty
Can detect structural complications
CT severity index - extent of necrosis and peripancreatic inflammation
Glasgow-Imrie Score Uses physiological and laboratory values from 48h after admission. A score of < 3 suggests a low probability of severe pancreatitis.
Ranson’s Criteria Similar scoring based on physiological and laboratory values. Has an admission and 48 component. Admission value of <3 suggests low risk. 48h score can suggest mortality rate.
May be referred to critical care for a few reasons:
Predicted need? - beware. Scoring systems not great at assessing critical care need itself
No definitive treatment. Supportive care:
No evidence for benefit from routine antibiotics If a triggering cause can be managed then this should be done e.g. gallstones.
No evidence for the concept of ‘pancreatic rest’. The idea behind this is to avoid the stimulation of enzyme secretion and reduce their autodigestive effects too. Patients with mild pancreatitis may be safely fasted for 3-4 days but patients with severe disease benefit from early nutrition.
Enteral nutrition prevents intestinal atrophy, improving gut mucosal function and thus reducing bacterial translocation and SIRS response. In severe pancreatitis it has demonstrated fewer complications and reduced cost.
Consider more distal feeding if challenging e.g. post pyloric tube
Consider PN support of EN if needing extra calorie input
Patients can be fasted for 3-4 days, and maybe up to a week
EN should be considered after this if there is a failure to resume normal diet
This is uncommon and associated with significant complications. Indications include:
Debridement of infected necrosis
Walled of necrosis (abscess)
Threshold of 30% of the pancreas necrotic (non enhancing on scan)
Gas on CT
Best to get a culture first
This may require IR intervention
Acute pancreatic fluid collection
Occurring within 4 weeks and without a well-defined wall
Fluid collection for >4 weeks and with a well defined wall