Acute Pancreatitis: Approach, Evaluation and Management

Etiology of Acute Pancreatitis

Causes of Acute Pancreatitis include:

Gallstones (most cases)
Alcohol (most cases)
Idiopathic
Hypercalcemia
Hyperlipidemia
Autoimmune
Post ERCP
Trauma
Mumps
Drugs (e.g., azathioprine,steroids or diuretics)

The causes of acute pancreatitis can be recalled from the mnemonic GET SMASH’D: gallstones, ethanol, trauma, steroids, mumps, autoimmune diseases, scorpion stings, hypertriglyceridemia, and drugs (e.g., azathioprine or diuretics).

Causes and Consequences of Acute Pancreatitis

Clinical Features of Acute Pancreatitis

There may be a history of cholecystitis or other complications of gallstones. Alcohol intake should be ascertained.

The patient complains of:

Severe abdominal pain radiating to the back or shoulder, which may be relieved by sitting forward
There may be associated nausea and vomiting

On examination there is:

abdominal tenderness with guarding and rebound tenderness
tachycardia
fever
jaundice
hypotension, and sweating
bruising around the umbilicus (Cullen’s sign) or in the flanks (Grey-Turner’s sign)

Acute Pancreatitis - Pathogenesis, Symptoms and Clinical Findings — Acute Pancreatitis – Pathogenesis, Symptoms and Clinical Findings

Acute Pancreatitis - Causes, Pathology, Symptoms and Signs, Investigations, Management and Complications — Acute Pancreatitis – Causes, Pathology, Symptoms and Signs, Investigations, Management and Complications

Differential Diagnosis

Any cause of an acute abdomen (e.g., cholecystitis, mesenteric ischemia, and intestinal perforation).
Myocardial infarction
Dissecting aortic aneurysm

Investigations

The following investigations are important in the patient with acute pancreatitis:

Serum amylase: markedly raised (over 1000 IU/mL). Amylase is also raised with cholecystitis and perforated peptic ulcer, but usually to a lesser extent. Serum lipase is also elevated and is more specific than amylase.
Abdominal x-ray: gallstones, pancreatic calcification indicating previous inflammation, an absent psoas shadow due to retroperitoneal fluid, and a distended loop of jejunum (“sentinel loop”).
Serum calcium: may be low.
White cell count: usually raised.
ECG: to exclude myocardial infarction.
Arterial blood gases: metabolic acidosis.
CXR: widened mediastinum in aortic dissection; gas under the diaphragm in perforated peptic ulcer.
Abdominal CT: assess severity.

Management of Acute Pancreatitis

Management is usually conservative.

Intravenous fluids should be given to maintain the circulating volume, and a central venous catheter may be helpful for assessing the volume of fluid required. If the patient is in shock (systolic blood pressure <90 mmHg), plasma expanders will be required.

Pain relief is with intravenous or intramuscular opiates (e.g., pethidine, 50-150 mg 4 hourly, or pentazocine, 30-60 mg 4 hourly, meperidine, fentanyl, or morphine with an antiemetic such as prochlorperazine, 12.5 mg 8 hourly).