Pancreatitis

Background

• Inflammation of the pancreas

Etiologies

• Gallstone
• Alcohol
• Tumour/Trauma
• Scorpion sting (Trinidadian)
• Microbiological
  • Viral: Mumps, Rubella, Varicella, Viral hepatitis, CMV/EBV/HIV, Coxsackievirus/Echovirus/Adenovirus
  • Bacterial: Mycoplasma, Campylobacter, Mycobacterium tuberculosis, Mycobacterium avium intracellular, Legionella, Leptospirosis
  • Parasitic: Ascariasis, Clonorchiasis, Echinococcus
• Autoimmune: SLE, Polyarteritis nodosa, Crohn disease
• Surgery: ERCP
• Hyperlipidemia
• Hypercalcemia
• Hypothermia
• Emboli/Ischemia
• Drugs
  • Steroids
  • Azathioprine
  • Furosemide
  • Mercaptopurine
  • Estrogen
  • Methyldopa
  • H₂ blockers
  • Valproic acid
  • Antibiotics: ampicillin, penicillin, ceftriaxone, isoniazid, macrolides, metronidazole, nitrofurantoin, rifampin, sulfonamides, tetracyclines
  • Antivirals: didanosine, interferon/ribavirin, nelfinavir, ritonavir
  • Antifungals: 5-fluorouracil, pentamidine, stibogluconate
  • Acetaminophen
  • Salicylates
  • Methanol
  • Organophosphates

Clinical Manifestations

• Acute abdominal pain, usually epigastric, sometimes radiating to the back
• Nausea and vomiting
• Fever
• Dyspnea
• Can lead to both endocrine and exocrine dysfunction, including diabetes mellitus and malabsorption

Prognosis

Ranson's Criteria

• On presentation
  • Sugar > 10
  • WBC > 16k
  • Elderly > 55 years
  • LDH > 350
  • AST > 250
• After 48h
  • Hct drop >10% from admission
  • BUN increase >5 mg/dL (>1.79 mmol/L) from admission
  • Ca <8 mg/dL (<2 mmol/L) within 48 hours
  • Arterial pO2 <60 mmHg within 48 hours
  • Base deficit (24 - HCO3) >4 mg/dL within 48 hours
  • Fluid needs > 6L within 48 hours

BISAP

• BUN > 8.9
• Impaired LOC
• SIRS
• Age > 60
• Pleural effusion

Differential Diagnosis

• Other causes of acute abdominal pain, including peptic ulcer disease, gallstones, cholangitis, cholecystitis, gastrointestinal perforation, intestinal obstruction, mesenteric ischemia, and hepatitis

Diagnosis

• Made based on the presence of two of the following three criteria:
  • Compatible history
  • Elevated lipase or amylase
  • Characteristic findings on imaging

Management

Pancreatic Necrosis

• Two forms
  • Acute necrotizing pancreatitis, which is present at the start, and is usually phlegmonous
  • Walled-off necrosis, which develops over the course of illness, and is usually an organized collection
• Both are sterile and both can become infected
  • No antibiotics warranted in acute necrotizing pancreatitis
  • Infection usually develops after about 10 days
• For patients with walled-off pancreatic necrosis, either sterile collections with severe symptoms, or suspected infection, they should be assessed for drainage1
  • Options include IR-guided drainage, EUS-guided drainage, or endoscopic necrosectomy
  • In general, if necrosectomy is indicated, it should be delayed by at least 4 weeks for the collection to mature
  • Percutaneous drainage has a risk of pancreatocutaneous fistula (about 30% if done without some form of surgical debridement)ross2014du2

Splenic Vein Thrombosis

• Monitor

Further Reading

• American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020;158(1):67-75.e1. doi: 10.1053/j.gastro.2019.07.064. PMID: 31479658.