Acute Pancreatitis

Question 1

A 56 year-old man presents with severe epigastric pain which radiates straight through to his back. His lipase level is 1860 U/L (normal 10-60). How would you assess the severity of the diagnosis and what is his management?

Impression/DDx/Goals

Answer 1

Impression:
Man’s presentation satisfies diagnostic criteria for acute pancreatitis (2/3). Would need to consider the important causes of pancreatitis. Most commonly alcohol related or gallstone disease. Concerned about complications of acute panc including SIRS response, pleural effusions, necrotising panc. Therefore, requires urgent treatment and management. Other DDx to consider:
- I GET SMASHED

Goals of management:

• Grade severity of acute pancreatitis using appropriate clinical tools and scoring systems, conduct targeted assessment with Hx/Ex/Ix
• Initiate timely management addressing underlying aetiology, considering need for alcohol withdrawal management

Question 2

Acute pancreatitis - Grading severity

Answer 2

Grading severity of acute pancreatitis
-	APACHE score
-	Glasgow Clinical severity score (PANCREAS)
o	P – Pa02 <60mmHg
o	A – age >55
o	N – Neutrophils (WCC>15)
o	C – Calcium <2mmol.L (corrected) 
o	R – renal function: urea >16
o	E – LDH >600, AST >200
o	A – Albumin <32
o	S – Sugars: BSL >10mmol

• Balthazar Criteria (imaging severity) - utilise Abdo US or CT
  o US: diffusely enlarged, hypoechoic pancreas, peri-pancreatic fluid, pancreatic necrosis, pancreatic pseudocysts (chronic panc)
  o CT: Fat stranding, peri-pancreatic fluid, assess for other complications (necrotising panc.)

Would also utilise thorough clinical assessment to clinically determine the severity of the presentation.

Question 3

Acute pancreatitis - History

Answer 3

History

• A to E assessment to distinguish instability
• Sx: SOCRATES
• PHX: gallstones disease, past pancreatitis
• RF: hypertriglyceridaemia, etc
• Meds, surgical Hx,
• SNAP – focus on alcohol intake

Question 4

Acute pancreatitis - Examination

Answer 4

Exam:
- Vital signs, end of bed assessment (patients can be quite sick)
- Gastro examination
o Cullen’s/ Grey-Turners sign (necrotising panc)
o Peritonism, epigastric tenderness
o Bowel sounds
o Systemic examination
o Signs of hypovolaemia
o SIRS
- Resp exam (pleural effusion signs)

Question 5

Acute pancreatitis - Investigations

Answer 5

Diagnostic criteria:

• Clinical signs
• Lipase >3x upper limit normal
• Imaging findings

Bedside: Vitals, VBG, CXR
Bloods: Lipase, EUC, LFT, FBC, blood cultures (if indicated), CRP/ESR, CMP (serum calcium)
Imaging: Abdo US/CT, CXR (pleural effusions)

For complications:

• CXR (pleural effusions)
• UECs (Renal function)

Question 6

Acute pancreatitis - Management

Answer 6

Disposition: depending on severity, but likely ICU if mod-severe as patients can deteriorate rapidly, often require intubation

Treatment otherwise is mainly supportive, unless;

• Gallstone related  ERCP, then patient is potentially for ERCP
• Alcohol related: thiamine replacement and AW mx

Supportive care – take ICU approach and move through ABCs of care:
A - ?intubation (as clinically indicated)
B – supplemental O2 if indicated by low SP02
C – vasopressors as indicated (Metaraminol infusion noradrenaline, etc), fluids replacement, manage electrolyte derangements
D – Treat underlying causes (alcohol  AWS mx, thiamine, benzo’s)
E – Antiemetics, analgesia, empirical antibiotics if indicated by assessment
F – Fluids, electrolyte replacement
G – Glucose, BSL monitoring, insulin-dex if req.
H and so on…