Acute Pancreatitis

Question 1

A 38YOF presents with severe epigastric pain and tenderness. her serum lipase is markedly elevated. how would you assess and manage her?

Answer 1

Impression
Acute pancreatitis is provisional diagnosis, as meets clinical criteria. Concerned about serious acute and chronic complications including necrotising panc, SIRS, pleural effusion, etc.

DDx
- Cholecystitis, cholangitis, AAA, PUD, biliary colic, SBO/LBO.

Aetiologies of acute panc
- Alcohol
- Gallstones
- Idiopathic
ETC (mumps, ERCP, etc)

Goals
- Rule out DDX, assess for acute complications of panc with primary survey and arrange appropriate supportive therapy and planning for definitive if relevant.

Question 2

Acute Pancreatitis - Assessment

Answer 2

Assessment
- Call for senior help, arrange for early gen surg consult

A - Patent, maintaining, tube pending GCS (lots of acute panc patients end up requiring ICU support and intubation.
B - RR/SP02 monitoring. Assess for evidence of pleural effusions, administer supplemental 02 as required.
C - HR/BP. IVC access, initial bloods: VBG, UEC, CRP/ESR, FBC, Lipase (confirm), BSL. Fluids if shocked (SIRS)
D - GCS
E F G as per normal.

Question 3

Acute pancreatitis - History

Answer 3

History
Atlanta diagnostic criteria;

• sx: pain (SOCRATES), bowel/urinary changes, N/V, etc
• RISKS: alcohol history, known gallstones disease, recent illnesses

Question 4

Acute pancreatitis - Examination

Answer 4

Examination

• General inspection: well vs unwell
• Vitals: HD stability
• Abdo exam: tenderness, peritonitis, Grey-turner/Cullens signs, distributive shock

Question 5

Acute pancreatitis - Investigations

Answer 5

Investigations
Key/diagnostic:
- serum lipase
- abdo US or CT abdo with pancreatic contrast

• Bedside: UA,
• Bloods: trope, coags, and the rest as per A to E
• Imaging: CXR for ARDS and pleural effusions

Severity scores

• Glasgow prognostic indicator
• APACHE (more for ICU)
• Balthazar criteria (for imaging severity)
• Ranson severity scale

Question 6

Acute pancreatitis - Management

Answer 6

Management
- Involve gen surg +/- ICU early depending on clinical condition

Management is largely supportive and appropriate dispositioning;

Supportive

• fluid resus based on HD status
• electrolyte replacement
• analgesia +/- antiemetics
• AWS and withdrawal management as required

Definitive

• alcohol: cessation support with pharm and non-pharm
• gallstones: gastro referral and +/- ERCP