15.11 Acute Pancreatitis

Question 1

a) List common causes of acute pancreatitis in the United Kingdom. (3 marks)

Answer 1

> > Gall stones.

> > Excessive alcohol intake
(causes thick,
proteinaceous secretions
resulting in obstruction).

> > Neoplasm resulting in obstruction
(head of pancreas or periampullary primary,
or metastasis from breast,
renal gastric, ovarian, lung).

Autoimmune diseases
such as sclerosing cholangitis,

viral infections
such as CMV and

the hepatitides,

trauma following surgery
or ERCP and idiopathic

Question 2

b) How is acute pancreatitis diagnosed? (3 marks)

Answer 2

revised Atlanta classification

Two of the following three features:
» Abdominal pain consistent with acute pancreatitis (acute onset,
persistent, severe, epigastric pain, often radiating to the back).
» Serum lipase (or amylase) at least three times greater than the upper limit
of normal.
» Characteristic radiological findings, usually CT.

Question 3

c) Describe the classification of severity of acute pancreatitis. (3 marks)

Answer 3

Atlanta classification

> > Mild acute pancreatitis:
• No organ failure.
• No local or systemic complications.

> > Moderately severe acute pancreatitis:
• Organ failure that resolves within 48 hours and/or
• Local or systemic complications.

> > Severe acute pancreatitis
• Organ failure persisting more than 48 hours.

Question 4

d) What are the specific principles of managing severe acute pancreatitis in a critical care environment?
(11 marks)

Answer 4

Airway, respiratory:
» Supplemental oxygen, keep oxygen saturations above 95%.
» May require noninvasive ventilation or intubation and positive pressure ventilation due to ARDS, diaphragmatic splinting (pain, intra-abdominal
oedema or fluid collections) or pleural effusions.

Cardiovascular:
>> Targeted fluid therapy 
(loss due to reduced oral intake, 
vomiting, extravasation, hypoalbuminaemia) 
with intra-arterial blood pressure and
cardiac output monitoring.

> > Inotropic support as required.

Neurological:

> > Sedation for invasive ventilation.
Pain control – consider organ dysfunctions in evaluating choices.

Endocrine:
» Blood glucose management.

Gastrointestinal:
» Enteric nutrition
(better outcome and cheaper),
jejunal if gastric not tolerated.

> > Parenteral nutrition if
intolerant of any enteric feeding.

> > Stress ulcer prophylaxis.

Haematological:
» Thromboprophylaxis:
thromboembolic deterrent stockings
or pneumatic compression devices.
Low-molecular-weight heparin if no evidence of
haemorrhage, unfractionated if evidence of acute kidney injury.

> > Need for thromboprophylaxis must be balanced against risk of massive haemorrhage in acute severe pancreatitis due to pseudoaneurysm development (often splenic).

Radiological management may be definitive
or temporise for surgical management: balloon tamponade or coil embolisation.

Infection, immune:
» Antimicrobials if infected pancreatic necrosis suspected, or other associated sepsis.
Ensure causative agent sought:
radiologically guided aspiration of pancreatic
or peripancreatic tissue if indicated.

Treatment should target gram negative
and fungal infection.

Renal:
» Minimise risk of acute kidney injury by optimising fluid status with cardiac output monitoring and by avoiding nephrotoxins.
Target urine output greater than 0.5 ml/kg/h.

> > Renal replacement therapy may be required.

Surgical Input:
» Acute pancreatitis secondary to
gallstones may require ERCP or
endoscopic sphincterotomy.

> > Necrosectomy if necrosed areas are infected.
May require repeat laparotomies
or laparostomy for ongoing lavage.