Acute Pancreatitis

The diagnosis of acute pancreatitis is based on a combination of both clinical (severe epigastric pain radiating to the back, relieved by sitting forward) and laboratory tests (elevated amylase and lipase- more specific- blood levels). The absolute value of the amylase and lipase blood level is not predictive of the severity or natural history of an attack of acute pancreatitis. Initial abdominal MRI or CT scan imaging is not necessary unless there is some doubt about the initial diagnosis. An abdominal ultrasound is more useful to identify gallstones as a possible etiology.

While the most likely cause for acute pancreatitis is gallstones and alcohol, other common causes include medications, elevated triglycerides, hypercalcemia, abdominal trauma, post-ERCP pancreatitis, and pancreas divisum. Inherited cause of pancreatitis should be considered if there is a strong family history of pancreatitis or an onset at a young age < 35 yrs. In a patient older than 40 yrs, the first attack of pancreatitis, should raise the suspicion of an underlying pancreatic cyst or a pancreatic mass.

While most patients with an attack of acute pancreatitis settle down within 5-7 days with appropriate bowel rest, intravenous fluids, correction of electrolyte and metabolic abnormalities, and analgesia; a small group may have a prolonged course with systemic disturbance (10-15%), often requiring ICU management, and rarely resulting in death (<3%). Identification of this subgroup earlier at the time of presentation or after 48 to 72 hours’ hospitalization using a combination of clinical, laboratory, and radiologic risk factors: (elevated hematocrit, elevated WBC, organ failure (renal or lung), elderly (>75yrs), comorbid illness, alcoholic pancreatitis); is critical to ensure appropriate triage with closer observation in an ICU with more directed supportive care of pulmonary, renal, circulatory and liver function. The best validated scoring system to predict severity of acute pancreatitis is the APACHE II scoring system (using a cut-off of 8). In patients with a predicted severe course, actual organ failure, or a suspicion of infection, a contrast CT scan may be indicated to assess for degree of pancreatic necrosis after 72 hours.

For most patients with mild acute pancreatitis, soft diet can be started after resolution of pain. For patients with severe pancreatitis, enteral nutrition (if possible) is preferred to parenteral nutrition. The role of prophylactic antibiotic for the management of pancreatic necrosis remains controversial. However, surgery should be considered in patients with infected pancreatic necrosis. For presumed biliary pancreatitis, urgent ERCP (defined as within 72 hours) is indicated for worsening biliary obstruction, ascending cholangitis, and severe pancreatitis. Cholecystectomy should be performed subsequently in all patients with gallstone pancreatitis. While most patients with acute pancreatitis will settle down symptomatically within 24 to 48 hours, prolonged symptoms should raise concerns about the development of pancreatic fluid collections.

At the Yale Pancreas Disease Program, we offer expert multidisciplinary evaluation, diagnosis, and treatment of patients with acute pancreatitis and recurrent acute pancreatitis.

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