What are the initial steps in the workup and management of pancreatitis?

Initial Workup and Management of Acute Pancreatitis

The diagnosis of acute pancreatitis requires at least two of three criteria: compatible abdominal pain, elevated pancreatic enzymes (serum amylase >3x normal or lipase >2x normal), and characteristic imaging findings, with serum lipase being the preferred diagnostic test due to its higher sensitivity and longer diagnostic window. 1, 2, 3

Diagnostic Approach

Clinical Assessment

• Acute pancreatitis typically presents with upper abdominal pain and vomiting with epigastric or diffuse abdominal tenderness 1
• Body wall ecchymoses (Cullen's sign at umbilicus, Grey-Turner's sign in flanks) may occasionally be present 1

Laboratory Testing

• Serum lipase is the preferred diagnostic test with higher sensitivity than amylase and remains elevated longer 3, 4
• Diagnosis requires serum amylase >4x normal or lipase >2x normal 1, 4
• In gallstone pancreatitis, early increases in serum aminotransferases or bilirubin may be observed 1
• After the acute phase, if etiology remains unclear, blood lipid and calcium concentrations should be measured 1

Initial Imaging

• Ultrasound should be performed early in all patients with suspected acute pancreatitis to evaluate for gallstones 1, 2
• CT scan is indicated for diagnostic purposes if clinical and biochemical findings are inconclusive 1
• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 2

Severity Assessment

Objective Criteria for Severity Stratification

• Clinical assessment alone is unreliable and will misclassify approximately 50% of patients 1
• The presence of organ failure (pulmonary, circulatory, or renal insufficiency) indicates severe disease 1
• Multifactor scoring systems like Glasgow criteria improve prognostication accuracy to 70-80% 1
• C-reactive protein (CRP) >210 mg/L in the first four days has prognostic value similar to objective scoring systems 1

Risk Stratification Tools

• Glasgow scoring system: ≥3 positive criteria indicates severe disease 1
• APACHE II scoring system can be used for early severity prediction 1
• CT severity index helps stratify patients (scores 0-3: mild disease with 3% mortality; scores 4-6: moderate with 6% mortality; scores 7-10: severe with 17% mortality) 2

Initial Management

Mild Acute Pancreatitis (80% of cases)

• Can be managed on general ward with monitoring of temperature, pulse, blood pressure, and urine output 1, 2
• Peripheral intravenous line for fluids and possibly a nasogastric tube are required, but indwelling urinary catheters are rarely warranted 1, 2
• Antibiotics should not be administered routinely as there is no evidence of benefit in mild cases 1, 2
• Early oral feeding (within 24 hours) is recommended rather than keeping patients nil per os 2

Severe Acute Pancreatitis (20% of cases)

• Should be managed in an intensive care unit or high dependency unit 1, 2
• Requires peripheral venous access, central venous line, urinary catheter, and nasogastric tube 1, 2
• Strict asepsis should be observed in the placement and care of invasive monitoring equipment 1, 2
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature is required 2, 5
• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast 2, 5

Fluid Resuscitation

• Adequate prompt fluid resuscitation is crucial in preventing systemic complications 2
• Intravenous crystalloids (preferably Lactated Ringer's solution) should be administered to maintain urine output >0.5 ml/kg body weight 2, 5
• For severe cases, non-aggressive fluid resuscitation at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg is recommended 5
• Total crystalloid fluid administration should be less than 4000 ml in the first 24 hours to avoid fluid overload 5

Pain Management

• Pain control is a clinical priority and should be addressed promptly 2
• A multimodal approach to analgesia is recommended, with intravenous opiates generally safe if used judiciously 2, 5
• NSAIDs should be avoided in patients with acute kidney injury 2

Nutritional Support

• For patients unable to tolerate oral intake, enteral nutrition is recommended over parenteral nutrition 2, 5
• Both gastric and jejunal feeding routes can be safely utilized 2, 5

Management Based on Etiology

Gallstone Pancreatitis

• Urgent ERCP (within 24 hours) should be performed in patients with concomitant cholangitis 2, 5
• Early ERCP (within 72 hours) is indicated for patients with high suspicion of persistent common bile duct stone, persistently dilated common bile duct, or jaundice 2

Common Pitfalls to Avoid

• Using hydroxyethyl starch (HES) fluids in resuscitation - these should be avoided 2, 5
• Routine use of prophylactic antibiotics in mild pancreatitis - only indicated for specific infections 1, 2
• Keeping patients nil per os unnecessarily - early oral feeding is beneficial when tolerated 2
• Overly aggressive fluid resuscitation - can worsen outcomes in severe cases 5
• Relying on specific pharmacological treatments - there is no proven specific drug therapy for acute pancreatitis 1, 2