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Editors

PauliPuolakkainen

Acute Pancreatitis

Essentials

  • Suspect acute pancreatitis in any patient with epigastric pain and in patients with impaired general condition of unknown aetiology and a history of alcohol consumption.
  • Identify acute pancreatitis at an early stage on the basis of the clinical presentation and determination of plasma pancreatic amylase.
  • Refer to a specialized care hospital all patients with acute pancreatitis who have
    • impaired general condition or other evidence of severe pancreatitis, or
    • clearly increased plasma CRP concentration.

Epidemiology

History and physical examination

  • Ask about alcohol consumption, biliary diseases and earlier episodes of pancreatitis.
  • Girdle-like epigastric pain radiating to the back is typical, starting after the cessation of alcohol consumption.
  • The general condition is most important.
  • Shock, respiratory distress, anuria and mental confusion may indicate severe pancreatitis.
  • Record epigastric tenderness and palpable masses.
  • Examine the skin of the flanks and navel for haematomas (Grey-Turner's or Cullen's sign).
  • Observe symptoms and clinical findings of peritonitis or intestinal paralysis.

Laboratory examinations

  • Determination of pancreatic plasma amylase concentration is suitable for basic diagnostics.
  • Pancreatic amylase > 65 U/l suggests pancreatitis, and concentrations above 200 U/l (over 3 times the upper limit of reference value) are considered diagnostic. Amylasis concentration does not correlate with the severity of pancreatitis.
  • Plasma lipase measurement can also be used in the diagnosis of acute pancreatitis. Its diagnostic value is similar to amylase but the concentration remains increased for a longer time (3-7 days).
  • Plasma CRP is a good test in the assessment of the severity of pancreatitis, although the concentration is not necessarily increased in the very initial stage of the disease. A concentration above 100 mg/l suggests severe pancreatitis.
  • High ALT concentration suggests gallstone pancreatitis Predicting Gallstone Pancreatitis with Laboratory Parameters.
  • If the aetiology is unclear it is advisable to determine plasma calcium and fasting plasma triglyceride concentrations in the initial stage of the disease already.

Radiological investigations

  • If the parient has both typical abdominal pain and clearly increased plasma amylasis concentration, making a pancreatitis diagnosis does not require imaging.
  • Contrast-enhanced computed tomography (CT) is the most accurate imaging method for diagnosing and assessing the severity of pancreatitis. Before administering the contrast medium, the patient's renal function should be checked.
  • Ultrasonography may give clues about gallstones as the possible aetiology of the pancreatitis, and, when needed, magnetic resonance cholangiopancreatography (MRCP) shows or excludes choledocholithiasis.

Treatment of mild pancreatitis

  • Even mild pancreatitis should be followed up in a hospital because of the risk of complications.
  • Sufficient early fluid resuscitation is the basis of conservative treatment. Even mild pancreatitis causes dehydration, and the minimum requirement for fluids during the first 24 hours is 3-4 l. Fluid resuscitation is continued according to the clinical condition and urine output. Ringer's solution is well suited for intravenous fluid therapy.
  • Adequate analgesia and follow-up are an essential part of the treatment.
  • Antimicrobial drugs, other medications and nasogastric suction have not been proven to have an impact on the healing of the disease. A nasogastric tube can be used if the patient vomits profusely because of intestinal paralysis.
  • Plasma CRP and glucose, basic blood count with platelets, plasma calcium, sodium, and potassium should be determined daily.
  • Sufficient rehydration is ensured by intravenous infusions with concurrent monitoring of diuresis, and peroral nutrition is started as soon as possible Enteral Versus Total Parenteral Nutrition for Acute Pancreatitis.

Biliary pancreatitis

Necrotizing pancreatitis Antibiotic Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis

  • The treatment of necrotizing pancreatitis should be concentrated to units of specialized care with the best experience and intensive care readiness because of the risk of complications and significant mortality.
  • The symptoms of severe pancreatitis, due to organ damages, include peritonitis shock, respiratory distress, anuria, and mental confusion.
  • A high plasma CRP concentration (above 100 mg/l) is, along with the clinical condition, multiple organ failure or -damage and information provided by contrast enhanced computed tomography, the most accurate indicator of severe pancreatitis.
  • The treatment of necrotizing pancreatitis has been changed in favour of conservative approach including aggressive fluid resuscitation (in the initial stage up to 4-6 l/day) and conservative measures maintaining cardiovascular and respiratory function (in intensive care). However, surgery may still be indicated. The primary indication for surgery is the infection of pancreatic necrosis. In the modern "step-up approach", the treatment methods progress from radiological drainage procedures to, according to need, mini-invasive or open surgery.
  • As a complication of severe pancreatitis, the intra-abdominal pressure may increase impairing respiratory function and diuresis. According to recent experience in the treatment of this so called abdominal compartment syndrome, when the intra-abdominal pressure is elevated to 25-35 mmHg, it is beneficial to perform laparotomy and leave the abdominal cavity unsutured to start the so-called "open abdomen" treatment.

    References

    • de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. N Engl J Med 2022;387(11):989-1000 [PubMed]
    • Chen H, Lu X, Xu B, et al. Lactated Ringer Solution Is Superior to Normal Saline Solution in Managing Acute Pancreatitis: An Updated Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2022;56(2):e114-e120 [PubMed]
    • Boxhoorn L, van Dijk SM, van Grinsven J, et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med 2021;385(15):1372-1381 [PubMed]
    • Dutta AK, Goel A, Kirubakaran R, et al. Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis. Cochrane Database Syst Rev 2020;3(3):CD010582 [PubMed]
    • Moody N, Adiamah A, Yanni F, et al. Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis. Br J Surg 2019;106(11):1442-1451 [PubMed]
    • Moggia E, Koti R, Belgaumkar AP, et al. Pharmacological interventions for acute pancreatitis. Cochrane Database Syst Rev 2017;4(4):CD011384 [PubMed]