What are the diagnostic and treatment approaches for pancreatitis?

Diagnosis and Management of Acute Pancreatitis

The diagnosis of acute pancreatitis requires at least two of three criteria: characteristic abdominal pain, elevated pancreatic enzymes (preferably lipase ≥2 times upper limit of normal), and characteristic findings on imaging, with treatment approach determined by severity classification (mild, moderately severe, or severe). 1, 2

Diagnosis

Clinical Assessment

• Upper abdominal pain and vomiting with epigastric or diffuse abdominal tenderness are common clinical findings 1, 2
• Occasionally, body wall ecchymoses (Cullen's sign at umbilicus, Grey-Turner's sign in flanks) may be present 1
• Diagnosis should be made within 48 hours of admission 1, 2

Laboratory Testing

• Serum lipase is preferred over amylase due to:
  • Higher specificity and sensitivity 1, 2
  • Longer elevation period (remains increased longer than amylase) 2
  • Diagnostic when ≥2 times the upper limit of normal 2
• Serum amylase ≥4 times above normal is also diagnostic in the appropriate clinical setting 1, 2
• Other helpful laboratory markers include C-reactive protein (CRP), procalcitonin, and white blood cell count 2, 3

Imaging Studies

• Ultrasound examination should be performed initially to detect gallstones, free peritoneal fluid, and bile duct dilation 2
• CT scan with IV contrast is indicated when:
  • Clinical and biochemical findings are inconclusive 2
  • Severe disease is predicted 1, 2
  • Patients show clinical deterioration 1, 3
  • Persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 1, 3
• MRI may provide additional information when a pancreatic tumor is suspected 1

Etiology Assessment

• The etiology should be determined in at least 80% of cases, with no more than 20-25% classified as "idiopathic" 1
• Evaluation should include:
  • Clinical history (alcohol intake, medications, recent surgeries) 1
  • Laboratory tests (liver function, serum calcium, triglycerides) 1, 4
  • Imaging (ultrasound for gallstones) 1, 2
  • ERCP when indicated (jaundice, dilated common bile duct) 1, 3

Severity Assessment

Classification

• Acute pancreatitis is classified as:
  • Mild (80% of cases, <5% of deaths) 1, 3
  • Moderately severe (organ failure resolving within 48 hours or local complications) 1, 4
  • Severe (persistent organ failure >48 hours, 20% of cases, 95% of deaths) 1, 3

Prognostic Indicators

• Clinical impression of severity 1
• Obesity 1
• APACHE II score in first 24 hours 1
• C-reactive protein >150 mg/L 1, 3
• Glasgow score ≥3 1
• Persistent organ failure after 48 hours 1

Treatment

Management of Mild Acute Pancreatitis

• Can be managed on general ward with monitoring of vital signs 1, 3
• Intravenous fluids for hydration 3, 5
• Regular diet with advancement as tolerated once pain and nausea subside 2, 3
• Pain management with analgesics 1, 5
• No routine antibiotics (only when specific infections occur) 1, 3
• No routine CT scanning unless clinical deterioration occurs 1, 3

Management of Severe Acute Pancreatitis

• Should be managed in high dependency unit or intensive care unit 1, 3
• Aggressive fluid resuscitation to prevent systemic complications 3, 5
• Oxygen supplementation to maintain arterial saturation >95% 3
• Nutritional support:
  • Enteral nutrition is preferred over parenteral nutrition 1, 3
  • Should be started within 48 hours of presentation 2, 3
  • Nasogastric route is effective in 80% of cases 1, 3
• Monitoring of organ function with appropriate support as needed 2, 3

Antibiotic Use

• No consensus on antibiotic prophylaxis in severe acute pancreatitis 1, 3
• If used, antibiotic prophylaxis should be limited to maximum 14 days 1, 3
• For infected pancreatitis, antibiotics should target the identified organisms 2
• Options for infected pancreatitis without multidrug-resistant organisms include meropenem, doripenem, and imipenem/cilastatin 2

Management of Gallstone Pancreatitis

• Urgent ERCP should be performed in patients with:
  • Severe gallstone pancreatitis 1, 3
  • Cholangitis 3
  • Jaundice 3
  • Dilated common bile duct 1, 3
• ERCP is most effective when performed within 72 hours of pain onset 3
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission or within two weeks 3

Management of Pancreatic Necrosis

• Image-guided fine needle aspiration is recommended for patients with:
  • Persistent symptoms and >30% pancreatic necrosis 3
  • Smaller areas of necrosis with clinical suspicion of sepsis 3
• Infected necrosis requires intervention (percutaneous, endoscopic, laparoscopic, or surgical) 3, 5
• Necrosectomy should be performed as late as possible 3, 5

Common Pitfalls to Avoid

• Routine use of antibiotics in mild pancreatitis 1, 3
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 3
• Overuse of CT scanning in mild cases showing clinical improvement 1, 3
• Using total parenteral nutrition when enteral nutrition is possible 1, 3
• Failing to determine etiology in at least 75-80% of cases 1