Pancreatitis: Difference between revisions

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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

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.

@@ Line 1: / Line 1: @@
-==Definition==
+==Background==
 *Inflammation of the pancreas
-==Etiology==
+=== Etiologies ===
 *'''[[Gallstone]]'''
 *'''Alcohol'''
@@ Line 89: / Line 88: @@
 **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
+**No antibiotics warranted in acute necrotizing pancreatitis
-*Infection usually develops after about 10 days
+**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 drainage[[CiteRef::baron2020am]]
-*If necrosectomy is indicated, it should be delayed by at least 4 weeks
+**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)[[iteRef::ross2014du]][[CiteRef::van brunschot2018en]]
 ===Splenic Vein Thrombosis===
 *Monitor
+== Further Reading ==
+* 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].
 [[Category:Gastroenterology]]