What are the symptoms and management of acute pancreatitis?

Symptoms and Management of Acute Pancreatitis

Acute pancreatitis presents primarily with epigastric pain radiating to the back, accompanied by nausea and vomiting, requiring prompt diagnosis and appropriate management based on disease severity to reduce morbidity and mortality.

Clinical Presentation

• Epigastric or diffuse abdominal pain is the classic symptom, often radiating to the back 1
• Pain is typically sudden in onset and severe in intensity 1, 2
• Nausea and vomiting are common accompanying symptoms 3, 4
• Abdominal tenderness on examination, particularly in the epigastrium 3
• In severe cases, body wall ecchymoses may appear (Cullen's sign at umbilicus, Grey-Turner's sign in flanks) 3
• Atypical pain presentations occur in approximately 50% of patients, with locations other than epigastric or belt-like upper abdominal pain 2
• Sharp pain (versus dull or cramping) is associated with increased disease severity and higher mortality 2

Diagnosis

Diagnosis requires at least two of the following three criteria:

1. Clinical features: Characteristic abdominal pain 3
2. Laboratory findings: Serum amylase at least four times above normal or lipase greater than twice the upper limit of normal 3
3. Imaging findings: Evidence of pancreatic inflammation 1, 5

Laboratory Assessment

• Serum lipase is more specific and remains elevated longer than amylase 3
• Complete blood count, liver function tests, triglycerides, and calcium should be obtained 4
• C-reactive protein (CRP) is useful for monitoring disease progression 3, 6

Imaging

• Abdominal ultrasound should be performed in all patients to evaluate for gallstones 3
• Contrast-enhanced CT scan should be delayed until at least 72 hours after symptom onset unless diagnosis is uncertain 5
• CT scan helps assess severity and identify complications such as necrosis 6

Severity Assessment

• Severity is classified as mild, moderate, or severe based on the revised Atlanta classification 3
• Mild: No organ failure or local/systemic complications 3
• Moderate: Transient organ failure (<48 hours) or local complications 3
• Severe: Persistent organ failure (>48 hours) 3
• Bedside Index of Severity in Acute Pancreatitis (BISAP) or Ranson criteria can help with risk stratification 4

Initial Management

Fluid Resuscitation

• Goal-directed fluid resuscitation with balanced crystalloids (Lactated Ringer's solution) is the cornerstone of initial management 6, 7
• Initial bolus of 10 ml/kg followed by 1.5 ml/kg/hr, with total crystalloid fluid <4000 ml in first 24 hours 6
• Avoid excessive fluid administration (>3 ml/kg/hr) as it may worsen outcomes 5
• Monitor urine output (target >0.5 ml/kg/hr) 6

Pain Management

• Intravenous opioids are the first-line treatment for pain control 4, 5
• Opioids are superior to NSAIDs for acute pancreatitis pain 5

Nutritional Support

• Early enteral or oral nutrition (within 24 hours) is recommended 7, 5
• Enteral feeding is preferred over parenteral nutrition 7, 5

Antibiotic Use

• Routine prophylactic antibiotics are not recommended, even in necrotizing pancreatitis 6, 5
• Antibiotics should be used only for documented infections 3, 5

Specific Etiologies

• For gallstone pancreatitis with cholangitis, urgent ERCP (<24 hours) is indicated 7, 5
• Without cholangitis, ERCP within 72 hours is adequate 5

Management of Complications

Pancreatic Necrosis

• Step-up approach is recommended for infected necrosis 6, 8
• Initial treatment with antibiotics, followed by drainage if needed 5
• Minimally invasive necrosectomy is preferred over open surgery 5
• Fine needle aspiration should be performed if infection is suspected in patients with >30% pancreatic necrosis 6

Pancreatic Pseudocysts

• Intervention is indicated for symptomatic collections, gastric outlet obstruction, or infection 8
• Wait at least 4 weeks from onset of pancreatitis before intervention to allow proper wall formation 8
• Internal drainage procedures are preferred over external drainage for mature cysts 8

Monitoring and Follow-up

• Ongoing clinical assessment for signs of deterioration (prolonged ileus, abdominal distension, fever) 3, 6
• Regular monitoring of laboratory parameters (leucocyte count, CRP, organ function) 3, 6
• Follow-up imaging (CT) should be performed only if clinical status deteriorates 6
• Referral to specialist centers for patients with extensive necrotizing pancreatitis or complications 6

Prognosis

• Overall mortality should be lower than 10% 3
• Mortality in severe acute pancreatitis can reach 15-30% 3
• Infected necrosis with organ failure has mortality rates of approximately 35% 3