Pancreatitis: Difference between revisions
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==Background== |
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*Inflammation of the pancreas |
*Inflammation of the pancreas |
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=== Etiologies === |
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*'''[[Gallstone]]''' |
*'''[[Gallstone]]''' |
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*'''Alcohol''' |
*'''Alcohol''' |
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==Clinical Manifestations== |
==Clinical Manifestations== |
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*Acute abdominal pain, usually epigastric, sometimes radiating to the back |
*[[Causes::Acute abdominal pain]], usually [[Causes::epigastric pain|epigastric]], sometimes radiating to the back |
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*Nausea |
*[[Causes::Nausea]] and [[Causes::vomiting]] |
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*[[Causes::Fever]] |
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*Fevers |
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*Dyspnea |
*[[Causes::Dyspnea]] |
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*Can lead to both endocrine and exocrine dysfunction, including [[diabetes mellitus]] and [[malabsorption]] |
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=== Prognosis === |
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====Ranson's Criteria==== |
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==Prognosis== |
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===Ranson's criteria=== |
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*On presentation |
*On presentation |
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**Fluid needs > 6L within 48 hours |
**Fluid needs > 6L within 48 hours |
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===BISAP=== |
====BISAP==== |
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*BUN > 8.9 |
*BUN > 8.9 |
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*Age > 60 |
*Age > 60 |
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*Pleural effusion |
*Pleural effusion |
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== Differential Diagnosis == |
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* Other causes of [[acute abdominal pain]], including [[peptic ulcer disease]], [[gallstones]], [[cholangitis]], [[cholecystitis]], [[gastrointestinal perforation]], [[intestinal obstruction]], [[mesenteric ischemia]], and [[hepatitis]] |
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== Diagnosis == |
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* Made based on the presence of two of the following three criteria: |
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** Compatible history |
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** Elevated lipase or amylase |
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** Characteristic findings on imaging |
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==Management== |
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===Pancreatic Necrosis=== |
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*For patients with walled-off pancreatic necrosis, either sterile collections with severe symptoms, or suspected infection, they should be assessed for drainage[[CiteRef::baron2020am]] |
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**Options include IR-guided drainage, EUS-guided drainage, or endoscopic necrosectomy |
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**Percutaneous drainage has a risk of pancreatocutaneous fistula (about 30% if done without some form of surgical debridement)[[iteRef::ross2014du]][[CiteRef::van brunschot2018en]] |
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== Further Reading == |
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* American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. ''Gastroenterology''. 2020;158(1):67-75.e1. doi: [https://doi.org/10.1053/j.gastro.2019.07.064 10.1053/j.gastro.2019.07.064]. PMID: [https://pubmed.ncbi.nlm.nih.gov/31479658/ 31479658]. |
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[[Category:Gastroenterology]] |
[[Category:Gastroenterology]] |
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Latest revision as of 16:30, 10 April 2026
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.
References
- ^ Todd H. Baron, Christopher J. DiMaio, Andrew Y. Wang, Katherine A. Morgan. 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.
- ^ Sandra van Brunschot, Janneke van Grinsven, Hjalmar C van Santvoort, Olaf J Bakker, Marc G Besselink, Marja A Boermeester, Thomas L Bollen, Koop Bosscha, Stefan A Bouwense, Marco J Bruno, Vincent C Cappendijk, Esther C Consten, Cornelis H Dejong, Casper H van Eijck, Willemien G Erkelens, Harry van Goor, Wilhelmina M U van Grevenstein, Jan-Willem Haveman, Sijbrand H Hofker, Jeroen M Jansen, Johan S Laméris, Krijn P van Lienden, Maarten A Meijssen, Chris J Mulder, Vincent B Nieuwenhuijs, Jan-Werner Poley, Rutger Quispel, Rogier J de Ridder, Tessa E Römkens, Joris J Scheepers, Nicolien J Schepers, Matthijs P Schwartz, Tom Seerden, B W Marcel Spanier, Jan Willem A Straathof, Marin Strijker, Robin Timmer, Niels G Venneman, Frank P Vleggaar, Rogier P Voermans, Ben J Witteman, Hein G Gooszen, Marcel G Dijkgraaf, Paul Fockens, Eric R Manusama, Mohammed Hadithi, Camiel Rosman, Alexander F Schaapherder, Erik J Schoon. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. The Lancet. 2018;391(10115):51-58. doi:10.1016/s0140-6736(17)32404-2.
