What are the diagnostic criteria and treatment options for pancreatitis?

Diagnostic Criteria and Treatment Options for Pancreatitis

The diagnosis of acute pancreatitis should be made within 48 hours of admission and requires a combination of clinical assessment, laboratory testing with lipase preferred over amylase, and imaging studies when needed. 1, 2

Diagnostic Criteria

Laboratory Tests

• Serum lipase activity ≥2 times the upper limit of normal is diagnostic and preferred over amylase due to higher specificity, longer elevation period, and higher sensitivity 2, 1
• Serum amylase activity ≥4 times above normal is also diagnostic in the appropriate clinical setting 1
• C-reactive protein >150 mg/l at 48 hours is a useful marker for severity assessment 1

Imaging Studies

• Ultrasound examination should be performed initially in all patients with suspected acute pancreatitis to detect gallstones, free peritoneal fluid, and bile duct dilation 1, 2
• Contrast-enhanced CT is indicated when:
  • Clinical and biochemical findings are inconclusive 1
  • Severe disease is predicted or suspected 1
  • Patients show persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission 1

Severity Assessment

• Severity should be classified according to the Atlanta criteria 1
• Prognostic indicators of severe disease include:
  • Clinical impression of severity 1
  • Body mass index >30 1
  • APACHE II score >8 in the first 24 hours 1
  • Glasgow score ≥3 1
  • Persisting organ failure after 48 hours 1

Treatment Options

Mild Acute Pancreatitis

• General supportive care on a general ward with monitoring of vital signs 1, 2
• No routine antibiotics (only when specific infections occur) 1, 2
• Regular diet with advancement as tolerated 2, 3

Severe Acute Pancreatitis

• Management in a high dependency unit or intensive care unit with full monitoring and systems support 1, 2
• Fluid resuscitation is crucial in preventing systemic complications 1, 3
• Nutritional support:
  • If required, enteral nutrition is preferred over parenteral nutrition 1, 2
  • Nasogastric feeding is effective in approximately 80% of cases 1

Gallstone Pancreatitis Management

• Urgent therapeutic ERCP should be performed within 72 hours in patients with:
  • Severe gallstone pancreatitis 1
  • Cholangitis 1, 2
  • Jaundice 1
  • Dilated common bile duct 1
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission 1

Antibiotic Use

• Evidence regarding prophylactic antibiotics is conflicting 1
• If used, antibiotic prophylaxis should be limited to a maximum of 14 days 1
• Antibiotics should be administered only to treat infected acute pancreatitis 2, 3

Management of Complications

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2
• CT-guided fine needle aspiration should be performed in patients with persistent symptoms and >30% pancreatic necrosis, or with smaller areas of necrosis and clinical suspicion of sepsis 1

Important Considerations

• The correct etiology of acute pancreatitis should be determined in at least 80% of cases, with no more than 20% classified as idiopathic 1
• Patients with severe acute pancreatitis should be managed in or referred to a specialist unit 1
• Early detection of patients with severe acute pancreatitis is crucial as they benefit from intensive care treatment started as soon as possible 4, 5
• The overall mortality should be lower than 10%, and less than 30% in those diagnosed with severe disease 2, 5