Acute pancreatitis: Clinical sciences

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Introduction0:00–0:48

Acute pancreatitis is an inflammation of the pancreas, most commonly caused by biliary stones, followed by alcohol use and hypertriglyceridemia, but can also be idiopathic.
There are many other causes of acute pancreatitis, including trauma, iatrogenic post-endoscopic retrograde cholangiopancreatography or ERCP, autoimmune disorders, genetic diseases, infections, malignancies, toxic exposure, and medications like thiazides, antiretrovirals, and valproic acid.
Depending on the severity of the disease, pancreatitis can range from mild to moderate or even severe, life-threatening pancreatitis.The first step in assessing a patient with signs and symptoms suggestive of acute pancreatitis is to perform the ABCDE assessment to determine if the patient is stable or unstable.

Unstable patient0:48–1:23

If the patient is unstable, start acute management and stabilize the airway, breathing, and circulation. Next, obtain IV access and initiate IV fluids for aggressive resuscitation.
Make sure the patient is NPO, and provide supportive care including pain management and antiemetic medication. Alright, now let's talk about stable patients.

Stable patient1:23–2:57

Start by taking a focused history and physical examination. Usually, patients with acute pancreatitis present with persistent, unremitting epigastric abdominal pain that radiates to the back, worsens after meals, and improves when leaning forward.
The pain is often associated with nausea and vomiting, while some patients might report a fever as well. It is also possible for patients to present with jaundice as a sign of biliary obstruction.
Additionally, some patients might develop tetany, or involuntary muscle spasms, as a result of hypocalcemia. Finally, don’t forget to ask about a history of similar previous episodes, cholelithiasis, or alcohol use.
Physical exam typically reveals epigastric abdominal tenderness, distention, or guarding. Some patients' physical examinations may show ecchymosis due to associated intra-abdominal or retroperitoneal bleeding.
Examples include the Cullen sign, or periumbilical ecchymosis; the Grey-Turner sign, or flank ecchymosis; the Fox sign, or inguinal ecchymosis; and the Bryant sign, or scrotal ecchymosis.
Lastly, in some cases, you might find signs of fluid sequestration like ascites or pleural effusion.These findings should make you suspect acute pancreatitis.The next step is to get labs.

Labs & imaging2:57–6:00

The obvious labs you should think of are lipase and amylase to confirm the diagnosis; but be sure to also check CBC, total and direct bilirubin, LFTs, LDH, glucose, calcium, and triglycerides, which will help determine the cause and severity.
First of all, if labs show that lipase and amylase levels are normal, then consider an alternative diagnosis.On the other hand, if lipase levels are elevated, with or without elevated amylase levels, you should suspect acute pancreatitis.
Other labs can help you identify the cause; for instance, elevated total and direct bilirubin with elevated LFTs typically indicates gallstone pancreatitis; while sometimes elevated LFTs may indicate liver disease from excessive alcohol use, hinting at alcohol-induced hepatitis; and elevated triglycerides may indicate hypertriglyceridemia-induced pancreatitis.
The remaining labs will be used later to help determine the severity of the disease.Next, you should also consider imaging to help confirm your diagnosis and look for possible causes.
For example, you will usually want to start with an abdominal x-ray and CT of the abdomen and pelvis with IV contrast. In certain cases, you can also consider an ultrasound and MRI with magnetic resonance cholangiopancreatography, or MRI/MRCP, because they are ideal for detecting gallstones.Okay, let's take a look at the imaging findings.
X-ray may often be normal or show non-specific findings, while CT may show peripancreatic free fluid, fat stranding, and pancreatic edema.
Additionally, you may or may not find an enlarged pancreatic duct. If the patient has gallstones, then an ultrasound may show stones or biliary sludge in the gallbladder, as well as stones in the biliary tree, and possibly a dilated biliary tree.
Finally, an MRI/MRCP might show an enlarged, edematous pancreas with or without peripancreatic free fluid. You may also see common bile duct or CBD obstruction.
If you have these findings, you can diagnose acute pancreatitis. Here’s a clinical pearl to simplify things!
In general, acute pancreatitis is diagnosed by meeting two out of three criteria: clinical presentation of epigastric abdominal pain, labs showing elevated serum lipase or amylase 3 times above the normal upper limit, and radiologic evidence of pancreatitis.Alright, now that we have a diagnosis, let’s talk about next steps.

Severity assessment6:00–8:35

It is important to assess the severity of the disease as it can range from mild to fatal, which will of course determine the management.Here’s a high yield fact!
The first 24 hours after presentation are critical for the patient’s prognosis and outcomes. If you suspect acute pancreatitis, it is crucial to start the patient on fluid resuscitation, pain management, and nutritional support.
Now, in general, severity can be based on the presence of organ failure, which can be seen with abnormal lab values, such as elevated LFTs to indicate hepatitis, or elevated creatinine to indicate acute kidney injury.
Severity is also based on complications from pancreatitis, including pancreatic pseudocyst or necrosis, peripancreatic splanchnic venous thrombosis, or abdominal compartment syndrome.
Here’s a clinical pearl to keep in mind! There are a variety of assessment scores to predict severity or mortality in acute pancreatitis.
For example, the Revised Atlanta classification divides acute pancreatitis into interstitial edematous pancreatitis, a less severe form, and necrotizing pancreatitis, a more severe form.
Another commonly used assessment to predict mortality in acute pancreatitis are the Ranson criteria, which include 11 prognostic signs.
The first 5 are assessed upon hospital admission, and include age over 55, elevated white blood cell count greater than 16,000, hyperglycemia greater than 200 mg/dL, LDH over 350 IU/L, and AST greater than 250 IU/dL.
The remaining 6 criteria are assessed after 48 hours and include hypocalcemia with a calcium level lower than 8 mg/dL, hypoxemia with a PaO2 lower than 60 mmHg, metabolic acidosis with a base deficit greater than 4 mmol/L, decline in hematocrit of 10% or greater, increase in BUN greater than 5 mg/dL, and fluid sequestration of more than 6 L, often in the form of pleural effusion or peripheral edema.Alright, let's say that there is no evidence of organ failure or systemic complications, or that the organ failure is transient.

Mild/moderate acute pancreatitis8:35–9:48

These patients have mild to moderate acute pancreatitis. Your first steps in management should be to start aggressive fluid resuscitation, adequate pain control, antiemetics, and early enteral feeding within the first 24 hours, so long as they can tolerate it given their nausea and vomiting.Now, if you suspect a stone in CBD, you can perform ERCP as a diagnostic and therapeutic tool.
If there are stones, patients should undergo cholecystectomy during the same hospital stay. Finally, some causes of pancreatitis require additional treatment.
For example, if there was a toxic, infectious, or medicine exposure, be sure to remove or address the causative agent. On the other hand, post-ERCP pancreatitis requires only supportive care and monitoring.Okay, now let’s go back and consider patients who have either persistent, multiorgan failure, or severe systemic complications.

Severe acute pancreatitis9:48–11:27

These patients have severe acute pancreatitis. In this case, you need to admit the patient to the ICU and start aggressive fluid resuscitation, pain control, and antiemetics.
You may attempt to start enteral feeding, either by mouth or through an NG tube, after 48 hours of treatment, especially if the patient is improving.
You should also consider repeating the abdominal CT after 72 hours, since complications such as necrosis are sometimes not visible on the initial CT but may appear later on.
Lastly, address specific underlying etiologies. For example, patients with infectious necrosis will require antibiotics.
On the other hand, patients with gallstones will need an ERCP, which is emergent in this case; the patient should also have a cholecystectomy.
Then, assess your patient’s response to treatment. If the response is adequate, you will continue current management, trying to advance enteral feedings and wean pain medications as tolerated.
If the response is inadequate, consider further assessment and management. In particular, you will want to assess for an underlying cause that could need intervention, such as necrotizing pancreatitis that would need a pancreatic necrosectomy, which involves draining and debridement of a necrotic area of the pancreas.
Alright, as a quick recap... Acute pancreatitis is an inflammation of the pancreas , most commonly caused by biliary stones, followed by alcohol use and hypertriglyceridemia.

Review11:27–12:49

First determine if your patient is unstable or stable. If they’re unstable, start acute management.
If the patient is stable, you can diagnose acute pancreatitis by meeting two out of three criteria: clinical presentation of epigastric abdominal pain, labs showing elevated amylase or lipase, and radiologic findings of pancreatitis.
Then, assess severity by looking for organ failure or complications. Mild or moderate cases can be managed conservatively with fluid resuscitation, pain control, antiemetics, early enteral feeding as tolerated, and treating the underlying cause.
Patients with severe pancreatitis should be admitted to the ICU for fluid resuscitation, pain control, and antiemetics. After 48 hours, consider starting enteral feedings, and after 72 hours, repeat an abdominal CT for missed complications.
Finally, if the patient shows adequate response, continue the current management, advance enteral feeding and wean pain medication as tolerated.
If there’s inadequate response, consider further assessment and management. adequate response continue the current management advance enteral feeding and wean pain medication as tolerated If there is inadequate response consider further assessment and