Acute Pancreatitis: From Causes to Treatment

Acute Pancreatitis: From Causes to Treatment

Acute pancreatitis (AP) is a serious condition that occurs when the pancreas becomes inflamed. It can lead to dangerous and life-threatening complications.

Causes of AP:

• Gallstones: Suspected when ALT > 150.

• Alcohol: Alcohol abuse is a common cause.

• Microlithiasis of the bile duct: Small stones in the bile duct can cause blockage and inflammation.

• Hypertriglyceridemia: High levels of triglycerides in the blood can cause pancreatitis.

• Genetic factors: Some people have a genetic predisposition to AP.

• Pancreas divisum: A rare condition where the pancreas has two parts.

• Post-ERCP: Endoscopic retrograde cholangiopancreatography procedure can cause pancreatitis.

• Hyperparathyroidism: High levels of calcium in the blood can cause pancreatitis.

• Medications: Some medications, such as azathioprine and thiazides, can cause pancreatitis.

Characteristics of abdominal pain:

• Sudden onset: Pain typically appears suddenly and intensely.

• Constant and piercing pain: Feeling of radiating and severe pain.

• Pain-relieving posture: Bending the knees and pressing them against the abdomen often reduces pain.

• Due to alcohol or cholelithiasis: Abdominal pain is usually not sudden and not severely localized.

High fever in AP?

• Necrotizing pancreatitis: High fever is common in cases of necrotizing AP.

Jaundice in AP?

• Serious prognosis: Jaundice is a sign that AP is serious and carries a high risk of complications.

Grey-Cullen sign:

• Black bruising on the back: Appears when blood clots behind the peritoneum.

• Bruising near the ribs or around the umbilicus: Bleeding from the pancreas into the peritoneal cavity.

Amylase and lipase characteristics:

• Amylase increases earlier and returns to normal sooner: Amylase is an enzyme released during pancreatitis, increasing faster than lipase.

• Lipase increases slower but persists longer: Lipase is a more specific indicator for AP.

Causes of elevated amylase:

• Acute, chronic, non-pancreatic pancreatitis: Pancreatic diseases.

• Acute abdomen: Appendicitis, perforated hollow organs, bile duct obstruction…

• Parotid gland disease, kidney failure, morphine-induced Oddi sphincter spasm: Other factors that can cause elevated amylase.

Ultrasound in AP:

• Enlarged pancreas partially or entirely: Abnormal enlargement of the pancreas.

• Indistinct pancreatic margins, uneven density, hypoechoic or mixed echoes: Indicates pancreatitis.

• May be fluid around the pancreas or in the abdomen: Signs of pancreatitis.

• Identifying the cause: Gallstones can be detected on ultrasound.

CT (Computed tomography) in AP:

• Enlarged or normal pancreas: CT images can show an enlarged or normal pancreas.

• Fatty infiltration: Fat accumulation in the pancreas.

• Irregular borders, signs of necrosis: Indicates severe damage.

Definitive diagnosis of AP:

• 2/3 of the following criteria:

• Abdominal pain

• Blood amylase or lipase > 3 times the normal value

• Lesions on imaging (ultrasound, CT)

Diagnosing the severity of acute pancreatitis:

• Mild: No organ failure or complications.

• Moderate: Temporary organ failure and local complications.

• Severe: Persistent organ failure > 48 hours.

Balthazar scoring:

• Degree of inflammation (Max 4 points):

• Normal pancreas

• Localized or diffuse enlargement

• Pancreatic structural changes, changes in the fat layer around the pancreas

• 1 fluid collection

• > 2 fluid collections

• Degree of necrosis (Max 6 points):

• 1/3 of the pancreas

• 1/2 of the pancreas

• > 1/2 of the pancreas

Imrie scoring:

• New: Age > 55, WBC > 15, G > 10, LDH > 600, Urea > 16

• Within the first 48 hours: Ca < 2; PaO2 < 60, Albumin < 32, AST > 100

• < 3: Mild, 3-5: Moderate, > 5: Severe

SIRS (Systemic Inflammatory Response Syndrome) criteria:

• M > 90

• f > 20 or PaCO2 < 32

• Rectal t* < 36 or > 38

• BC < 4 or > 12G/l

• > 2 criteria indicate severe pancreatitis

Assessing organ failure according to Atlanta:

• Hypovolemic shock HA < 90mmHg

• PaO2 < 60

• Creatinine > 2mg/l

• Gastrointestinal bleeding > 500ml/24h

• 1 organ failure factor

• > 1 multiple organ failure

Local complications of pancreatitis:

• Pancreatic fluid collection, necrosis, and infection: Common complications of AP.

• Pancreatic pseudocyst: Appears after 4 weeks.

• Pancreatic abscess, pancreatic duct fistula into the abdomen: Serious complications.

• Vascular damage, bleeding: Can be life-threatening.

Systemic complications of AP:

• Respiratory failure, renal failure, cardiovascular collapse: Complications that can be life-threatening.

• Gastrointestinal bleeding: Causes severe blood loss.

• ARDS (Acute Respiratory Distress Syndrome): A severe complication of AP.

• DIC (Disseminated Intravascular Coagulation): Can cause abnormal bleeding.

Fluid resuscitation in AP:

• 250-300ml/h (usually 4-6 liters of isotonic NaCL/24h): Fluid resuscitation is crucial.

• If there are complications, place a central line to maintain CVP 8-12mmHg: Monitor and adjust fluid intake as needed.

Indications for vasopressors:

• CVP reaches 8-12mmHg but MAP < 65mmHg: Use vasopressors to raise blood pressure.

• Use norepinephrine or adrenaline, consider dobutamine if there is evidence of heart failure: Choose the appropriate drug based on the patient’s condition.

Pain management in AP:

• NSAIDs or opioids: Use appropriate pain medications.

• Consider morphine: Morphine can be effective but requires close monitoring.

Antibiotic use in AP:

• Only use when suspected evidence of infection or high risk of infection: Don’t use antibiotics arbitrarily.

• Ceph 3, carbapenems, quinolones, metronidazole: Choose the appropriate antibiotic based on the patient’s condition.

Nutrition for patients with AP:

• Total parenteral nutrition for the first 24-48 hours, then gradually introduce oral feeding, early feeding via a tube is possible: Nutrition is important for recovery.

• High protein and carbohydrate diet, low fat: Choose a suitable diet.

If triglyceride levels are excessively high:

• Plasmapheresis: Can be used to reduce triglycerides.

Transfer to the ICU when:

• Decreased blood oxygen saturation, low blood pressure not responding to fluid resuscitation, kidney failure: Monitor closely and transfer to the ICU when needed.

• BMI > 30, urine output < 50ml/h, M > 120, brain disease, increased pain medication dosage: Risk factors to monitor and manage promptly.

Surgical indications:

• Necrotizing AP with infection: Surgery is necessary to manage complications.

Treatment of necrotizing AP with infection:

• Identify evidence of infection through culture of the necrotic area: Identify the causative bacteria for effective treatment.

• Antibiotics:

• Gram (-): Carbapenems, quinolones + metronidazole, cepha + metronidazole

• Gram (+): Vancomycin for 3 weeks

• Surgical removal of the necrotic area or percutaneous drainage: Manage the necrotic area to prevent infection.

Goals of fluid resuscitation in AP:

• Heart rate < 125 beats/min

• MAP 65-85mmHg

• Urine output 0.5-1ml/kg/h

• HCT 35%-44% within 48 hours

• Decrease in blood urea nitrogen

Acute pancreatitis is a serious condition that can be life-threatening. Early and effective treatment is crucial to prevent complications and ensure patient recovery.