EUH Resident Report: A review of acute pancreatitis.

The Bottom Line: The incidence of acute pancreatitis is increasing in the United States, and the disorder is now one of the most common reasons for hospitalization with a gastrointestinal condition. Accurate diagnosis of acute pancreatitis requires at least two of the following three diagnostic features: abdominal pain consistent with acute pancreatitis, serum lipase or amylase levels that are at least 3 times the upper limit of the normal range, and findings of acute pancreatitis on cross-sectional imaging (computed tomography [CT] or magnetic resonance imaging). The essential requirements for the management of acute pancreatitis are accurate diagnosis, appropriate triage, high-quality supportive care, monitoring for and treatment of complications, and prevention of relapse (Forsmark, Swaroop, & Wilcox, 2016).

Reference: Forsmark CE, Swaroop VS, Wilcox CM. Acute Pancreatitis. New England Journal of Medicine, 2016 Nov 17; 375(20): 1972-1981. doi:10.1056/NEJMra1505202

Tenner S, Baillie J, DeWitt J, Swaroop VS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. American Journal of Gastroenterology, 2013; 108: 1400-1415. doi: 10.1038.ajg.2013.218

Summary:  During the past decade, several limitations have been recognized that led to a working group and web-based consensus revision. Two distinct phases of AP have now been identified: (i) early (within 1 week), characterized by the systemic inflammatory response syndrome (SIRS) and / or organ failure; and (ii) late ( > 1 week), characterized by local complications. It is critical to recognize the paramount importance of organ failure in determining disease severity (Tenner et al, 2013).

Recommendations of initial management of AP (Tenner et al, 2013):

  1. Aggressive hydration, defined as 250 – 500 ml per hour of isotonic crystalloid solution should be provided to all patients, unless cardiovascular, renal, or other related comorbid factors exist. Early aggressive intravenous hydration is most beneficial during the first 12–24 h, and may have little benefit beyond this time period (strong recommendation, moderate quality of evidence).
  2. In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed (conditional recommendation, moderate quality of evidence).
  3. Lactated Ringer ’ s solution may be the preferred isotonic crystalloid replacement fluid (conditional recommendation, moderate quality of evidence).
  4. Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next 24 – 48 h. The goal of aggressive hydration should be to decrease the BUN (strong recommendation, moderate quality of evidence).

 

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