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Pancreatitis

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Pancreatitis is a condition characterised by the inflammation of the pancreas. These patients are usually managed conservatively. Your aim is to try to find out the underlying cause, optimise managing them conservatively whilst observing for complications.

Signs and symptoms:
  • Upper abdominal pain (usually described as radiating to the back)
  • Pain that gets worse after eating
  • Nausea and vomiting
  • Fever
  • Tachycardia
Causes:
The most common causes can be remembered with the mnemonic ‘I GET SMASHED’. The first 4 letters represent the most common causes of pancreatitis.

I - Idiopathic
G - Gallstones/Genetic (Cystic Fibrosis)
E - Ethanol
T - Trauma
S - Steroids
M - Mumps (and other infections)/Malignancy
A - Autoimmune
S - Scorpion sting
H - Hypercalcaemia/Hypertriglyceridemia
E - ERCP
D - Drugs (Medication)

Ensure these patients have an accurate alcohol & drug history including any recreational use.

Complications:
It is important to be aware of the complications which pancreatitis can lead to. Severity scoring can help predict which patients are more likely to develop complications (& hence these patients might be admitted to HDU/ITU for closer follow up). They can be broken down into local and systemic.

Local:
Ongoing inflammation can lead to ischaemic infarction of the tissue which could cause pancreatic necrosis. This can be suspected in patients with:
  • severe acute pancreatitis
  • signs of sepsis/prolonged raised inflammatory markers
  • clinical deterioration (after 72h usually)
Necrotic tissue is prone to infection and may require specialist management (e.g. drainage) hence the need to escalate your concerns to seniors.

Pancreatic pseudocysts can also occur, this a collection of fluid containing enzymes, blood and necrotic tissue. These are often managed conservatively as the majority will respond however they are also prone to haemorrhage/rupture/infection and a sudden deterioration must raise concern.

Systemic:
Pancreatitis can also lead to systemic complications. These include pulmonary complications such as ARDS or pulmonary oedema. Inflammatory changes may also extend to the kidneys, stomach, colon which can lead to related complications.

Assessment:
Pancreatitis can present with a mix of symptoms outlined earlier. However, it very frequently just presents upper abdominal pain which may or may not be radiating the back. Therefore, keeping wide differentials when assessing a patient with epigastric pain is necessary as that symptom is representative of many conditions.

Pancreatitis is a severe condition with a high mortality rate (21.1%). It is therefore important to recognise the severity of pancreatitis and investigate for it.

Risk Scoring:
The level of serum amylase does not have any bearing onto the severity of the pancreatitis itself. Severity can be calculated using several scores. These include the modified Glasgow criteria, APACHE II and the Ranson criteria.

The modified Glasgow criteria can be remembered with the mnemonic PANCREAS. This scoring system should only be calculated at 48 hours and a score of 3 or more would suggest a severe pancreatitis.
  • P(partial pressures) - pO2 < 8kPa 
  • A(age) - Age > 55
  • N(neutrophils) - White blood cell > 15x10^9//L
  • C(calcium) - serum calcium < 2 mmol/L 
  • R(renal function) - urea >16 mmol/L
  • E(enzymes) - lactate dehydrogenase (LDH) >600U/L or AST >200U/L
  • A(albumin) - albumin < 32g/L
  • S(sugar) - glucose >10 mmol/L
Initial investigations:
Bloods:
Routine bloods including LFTs and lactate are warranted as well as serum amylase and serum lipase. Serum lipase is being a preferred diagnostic marker due to its accuracy. Bone profile i.e. calcium, triglycerides, alcohol level on admission can all further assist on identifying the underlying cause (to subsequently guide management).

Imaging:
US Abdomen is often if the underlying cause is not know. It is typically used to identify gallstones or biliary duct dilatation. It is not to look for pancreatitis specifically. This can then inform whether there is risk of an obstructing stone that may need an ERCP to remove it.

CT imaging is not routinely used to diagnose pancreatitis. The findings of necrosis usually become clearer after 48-72 hours and that is when CT imaging could be considered. It could be considered if the clinical assessment & blood tests prove inconclusive with pancreatitis.

Management:
There is no curative management for acute pancreatitis therefore supportive treatment is the mainstay. You would attempt to treat the underlying cause particularly if gallstones were present.

Supportive therapy includes:
  • Oxygen as required
  • Aggressive fluid resuscitation
    • Aim for observations in normal range and an adequate urine output of at least 0.5 ml/kg/h (ideally 1 ml/kg/h). Fluid is usually given at a rate of 5-10 ml/kg/h or higher unless there's concerns of the patient being at risk of fluid overload.
  • Analgesia
    • Acute pancreatitis is severely painful and may require strong analgesia such as IV opiates, perhaps even via a PCA. If oral analgesia is insufficient, discuss these patients with seniors & your local pain team/anaesthetic services
  • Nutrition
    • Consider whether patients need NJ feeding in patients with severe disease as this is unlikely to resolve within a few days
    • Oral feeding can be built up as the patient tolerates (unless there's ileus or too much pain to allow this)
Usually prophylactic antibiotics are not used, however it would be best to ask seniors as some consultants may give it regardless.

Ensure you monitor for signs of sepsis, deterioration or haemodynamic instability as you should rapidly discuss this with your seniors and consider whether escalation to ITU may be warranted.

References
Mortality prognostic factors in acute pancreatitis, Popa CC, Badiu DC, Rusu OC, J Med Life. 2016 Oct-Dec; 9(4): 413–418.
UpToDate - on Acute Pancreatitis

By Jiansheng Kiam
Edits by Dr Akash Doshi CT2

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