Acute Pancreatitis

Steven B. Goldin, MD
University of South Florida
 J.H.

• JH is a 64-yr-old male admitted to an outside

hospital with a 4 day history of progressively
worsening epigastric pain without radiation.
 History

What other points of the history do you

want to know?
 History, J.H.
Consider the Following

• Characterization of • Pertinent PMH, ROS,

symptoms MEDS.
• Temporal sequence • Relevant family hx.
• Alleviating / • Associated signs and
Exacerbating factors: symptoms
 HPI J.H.

• Pain is constant and unremitting, going

through to his back
• Pain started after beer and pizza 4 days prior,
progressively worsening since
• Nausea and vomiting x 3
• Some indigestion history, never like this
• No relief with OTC Pepcid, Mylanta or Advil
 History, J.H.
• No significant past medical or surgical history
• No medications
• No allergies to medications
• Smokes 1ppd x 40 yrs, and drinks ethanol
heavily. He denies drug use.
• Family history was noncontributory.
What is your Differential Diagnosis?
 Differential Diagnosis
Based on History and Presentation

• Cholecystitis • Appendicitis
• Choledocholithiasis • Hepatitis
• PUD • Diabetes
• Gastritis • Rectus hematoma
• Pancreatitis • Pneumonia
• Bowel obstruction • Pyelonephritis
• Mesenteric ischemia • Trauma w/ duodenal
• Gastroenteritis hematoma.
Physical Examination

What would you look for on

physical examination?
 Physical Examination, J.H.

• Vital Signs: T 38.5 BP 120/70 P 100 R18

• Appearance: lying still in moderate distress. Not
jaundiced and sclera were anicteric. His mucous
membranes were dry.
• Resp: His lungs were clear to auscultation.
• CV: heart was regular and without murmurs,
rubs, or gallops.
 Physical Examination, J.H.
• Abdomen: soft, moderately distended, tender in
the mid-epigastric region and right upper
quadrant. No palpable masses. Bowel sounds
were positive.
• Extremities: without cyanosis, clubbing, or
edema.
• Rectal exam: no masses, guaiac neg.
Would you like to revise your
Differential Diagnosis?
 Revised Differential

• Cholecystitis • Gastroenteritis
• PUD • Hepatitis
• Pancreatitis • Rectus hematoma
• Bowel obstruction • Pneumonia
• Mesenteric ischemia
 Laboratory

What would you obtain?

 Labs
Consider the following

• CBC, Electrolytes, LFT’s, CMP, LDH,

Amylase, Lipase, PT, PTT, Urinalysis, ABG,
 Lab Results, J.H.
CBC: Hb /Hematocrit 10/30
WBC 17
Electrolytes : Na 135, K3.0, Chloride 98,
CO2 37, BUN 15, Cr 1.1,
Glu 100, Calcium 8.1
LFT’s : AST 260, ALT 220, Total
Bili 1.9, Alk phosphatase
110
Amylase: 326
Lipase: 245
PT/PTT: Normal
U/A: Normal
Other: LDH 375
 Lab Results, Discussion
• This patient has a hypokalemic hypochloremic metabolic
alkalosis from vomiting.
• He has an elevated amylase and lipase consistent with
pancreatitis.
• On admission he has 4 out of 5 of Ranson’s criteria and
can be expected to become very sick.
• There are 6 more of Ranson’s criteria that should be
tracked over the next 48 hours.

Can you list Ranson’s criteria?

Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death

On Admission
Non-biliary Biliary
Age >55 >70
WBC >16 >18
Glucose >200 >220
LDH >350 >400
SGOT >250 >250
Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death

During the Initial 48 Hours

Non-biliary Biliary
Hematocrit decrease >10% >10%
BUN increase >5 mg/dL >2 mg/dL
Calcium <8 mg/dL <8 mg/dL
Arterial Po2 <60 ...
Base deficit >4 mEq/L >5 mEq/L
Fluid sequestration >6 L >4 L
 Ranson’s Prognostic Signs that Correlate with
the Risk of Major Complications or Death

Number of 0-2 3-4 5-6 7-8

Prognostic Signs
% spending >7 4 40 90 100
Days in ICU
Mortality (%) 2 15 40 100
Ranson’s Early Objective Prognostic Signs that Correlate
with the Risk of Major Complications or Death

Note
1. The amylase and lipase levels are not prognostic
signs and do not relate to the severity of the attack
or prognosis.
2. LDH must usually be specifically ordered.
It is not included with most comprehensive
metabolic panels or with most liver function tests.
Interventions at this point?
 Interventions at this point
• IVF – LR Bolus 1-2 liters then LR at 150cc/hr – titrate
to urine output/volume status

• NPO

• Foley catheter

• NG Tube

• Admission to ICU
List common etiologies for
Pancreatitis
 Pancreatitis

• Alcohol * • Medications
• Gallstones* • Infection
• Hyperlipidemia • Post-op/Post-procedure
• Trauma • Other
• Tumor • Idiopathic
• Ischemia
 Studies

What would you order ?

 Studies

Obstruction Series/Acute CT Scan: Abd/Pelvis

Abdominal Series etc. CT Scan: Other
Flat/Upright Abdomen HIDA Scan
PA/Lat Chest MRCP
RUQ US OTHER: EKG
US GB
 Discussion of Studies

• Ultrasound of right upper quadrant is indicated

to evaluate gallbladder and bile duct for stones.
• CT scan should be done after initial
stabilization. IV contrast is useful to assess
pancreatic viability. Use of IV contrast on
presentation is debated.
His initial CT Scan is shown below:
 Discussion of imaging study

• This is a CT scan of the abdomen done with both oral

and IV contrast. It demonstrates edema surrounding
the pancreas and is consistent with the laboratory
results suggesting pancreatitis. No significant
pancreatic necrosis is noted.
• My preference is to not use IV contrast on admission if
pancreatitis is suspected due to the toxic nature of the
dye and the rarity of finding infection on presentation.
I do use IV contrast later on in the hospitalization to
better discern the amount of necrosis that has resulted
as long as the patients renal function is acceptable.
Would you like to revise your
differential diagnosis?
 Revised Differential Diagnosis

• Acute Pancreatitis
• Choledocholithiasis
• Cholecystitis
• Perforated ulcer
What next?
 Supportive measures

• Nothing by mouth • Nutritional support

• early oral feedings may increase the
severity of pancreatic inflammation. • Proton pump inhibitors
Oral feedings should be withheld until
resolution of abdominal pain, fever, and • DVT prophylaxis
leukocytosis

• Fluid and electrolyte • Antibiotics (debated)

repletion and resuscitation
• Analgesics
• Respiratory support
 Timing of cholecystectomy

• Gallstones are present in 60% of non-

alcoholic patients with pancreatitis and if
allowed to persist, 36 - 63% will develop
recurrent bouts of pancreatitis.
Cholecystectomy reduces this risk to
2 - 8%.
 Timing of cholecystectomy

• 75% of patients with acute abdominal pain,

gallstones, and elevated amylase have no gross
evidence of significant pancreatitis.
Cholecystectomy is safe in this group.
• In patients with gross evidence of pancreatitis,
80% have mild disease and cholecystectomy is
safe but does not alter the course of the
pancreatitis
 Intra-Operative Cholagiogram (IOC)
during Laparoscopic Cholecystectomy
 The timing of cholecystectomy

• In patients with severe pancreatitis there is an

82.6% morbidity and 47.8% mortality from
cholecystectomy if performed within the initial
48 hours. If deferred until the signs of
pancreatitis have subsided, morbidity and
mortality fall to 17.8% and 11.8%
respectively.
 Timing of cholecystectomy

• In patients with severe pancreatitis and an

obstructed biliary tree secondary to
choledocholithiasis, ERCP and sphincterotomy
significantly reduce morbidity related to
biliary complications but do not alter the
course of the pancreatic inflammation.
ERCP
 Hospital Course

• This patient deteriorates with non-operative

treatment. He develops high fevers and
hypotension.

• What could be happening?

• What would you do next?
Repeat CT Scan is shown below
What do you see?
 CT Findings

CT scan now shows air in the lesser sac. This is

diagnostic of infected pancreatic necrosis.

What next?
 What next?

• Supportive Treatment
• Elective Cholecystectomy if caused by
gallstones.
• Endoscopy with ERCP if obstructing stone is
identified in the common bile duct.
• OR if infected
 Management
The patient was started on broad spectrum
antibiotics and taken to the operating room for
pancreatic debridement, cholecystectomy, and
placement of large axiom sump drains. A
jejunal feeding tube was also placed at this
time.
Temporary Abdominal Closure

Sump Drain
 Management

This patient was slowly weaned from his

vasopressor agents and ventilator. Tube
feedings were started two days after his
debridement. The patient eventually made a full
recovery and was discharged from the hospital
approximately 4 months after presentation.
 Management
Operative Options include
• Debridement and drainage-Mortality 13.9%. 58.3%
of patients can be treated with one surgical procedure.
• Debridement & packing, and dressing changes every
2 - 3 days. Mortality 10.7%.
• My preference is to debride and drain if all necrotic
debris can be easily removed. Otherwise I pack and
return to the operating room every 48 hours until the
necrotic tissue is fully debrided. At that time, I place
drains and close the patient.
 Management

• Patients who are not infected should not be

operated on.
• Bradley - Neither the existence nor the extent of
necrosis can be used as an indication for
surgery. (90.4% survival in patients treated
conservatively with over 50% necrosis of the
gland and no infection).
 Management

• The use of antibiotics in patients with necrosis

without infection is debated. Overall mortality
does not seem to change significantly, but there
is a lengthening of time to develop infection
with the use of antibiotics. Antibiotic use,
however, has been suggested to increase the risk
of infection with resistant organisms.
 Management
• The number one determinant of survival is whether
infection of the necrotic tissue occurs.

• Infection is demonstrated by air in the lesser

sac/retroperitoneum. Infection can occur without air
and if suspected, needle aspiration should be attempted.

• Caution is warranted when attempting needle aspiration

due to the risk of passing the needle through the colon
or stomach. Once done, a previously uninfected
collection will likely become infected.
Pancreatic Necrosis
 Clinical Signs of Infection

• Fever >101F 100%

• Abdominal distention 94%
• Pneumonia or effusion 89%
• Leukocytosis (>10,000/mm3) 78%
• Abdominal mass 71%
• Hypotension (BP <90 mm Hg) 39%
• Renal failure 39%
• Coma 28%
• Elevated serum amylase 28%
Discuss Potential Complications of
Acute Pancreatitis
Pleural Effusions
Pancreatic Ascites
 Summary
Treatment of Acute Pancreatitis

• On presentation, determine the potential for complications

– Ranson’s criterion are one method.
• Nasogastric suction
• No oral feedings until pancreatitis subsides
• Monitor and maintain intravascular volume
• Respiratory and nutritional support
• Antibiotics (selective)
• Suspect and treat pancreatic sepsis aggressively
• Surgery only for infected pancreatic necrosis
QUESTIONS ??????
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