What is the approach to diagnosing and treating pancreatitis?

Diagnosis and Management of Acute Pancreatitis

Diagnostic Approach

Diagnose acute pancreatitis when at least 2 of 3 criteria are present: abdominal pain consistent with pancreatitis, serum lipase and/or amylase >3 times the upper limit of normal, and characteristic findings on imaging. 1

Clinical Presentation

• Look for epigastric or diffuse abdominal pain radiating to the back, accompanied by nausea and vomiting with epigastric tenderness on examination 2
• The diagnosis must be established within 48 hours of admission 3

Laboratory Testing

Serum lipase is the preferred diagnostic marker over amylase due to higher specificity for pancreatic tissue, longer elevation duration (remains elevated 4-8 days vs 2-3 days for amylase), and superior diagnostic accuracy 3, 1, 2

• Diagnostic threshold: Lipase ≥2-3 times the upper limit of normal is diagnostic in the appropriate clinical setting 1, 2
• Amylase ≥3-4 times the upper limit of normal can be used if lipase is unavailable 1, 2
• Elevations <3 times the upper limit have low specificity and are consistent with but not diagnostic of acute pancreatitis 1
• Do not order both amylase and lipase together - this marginally improves diagnostic efficiency but increases costs unnecessarily 4

Imaging Studies

Obtain abdominal ultrasound at admission primarily to identify gallstones as the etiology, not for diagnosing pancreatitis itself 1, 2

Use contrast-enhanced CT selectively when: 1, 2

• Clinical and biochemical findings are inconclusive or uncertain
• Severe disease is predicted
• Evidence of organ failure is present
• Clinical deterioration occurs 6-10 days after admission 3

Contrast-enhanced CT is the gold standard for confirming diagnosis when needed and for assessing disease severity and prognosis 3, 1, 5

Etiologic Workup

Determine the etiology in at least 80% of cases; no more than 20% should remain idiopathic 3

• Obtain abdominal ultrasound to detect gallstones, bile duct dilation, and free peritoneal fluid 2
• Check AST, bilirubin, and alkaline phosphatase levels to distinguish biliary from non-biliary causes 6
• Obtain detailed alcohol use history 5

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Severity Assessment

Classify severity as mild, moderately severe, or severe based on the presence and duration of organ failure 3, 2

Key Severity Markers

Persistent organ failure (cardiovascular, respiratory, and/or renal) lasting >48 hours is the most reliable marker of severe disease and mortality risk 3, 1, 2

• Organ failure resolving within 48 hours should NOT be considered an indicator of severe pancreatitis 3
• Patients with persistent organ failure AND infected necrosis have the highest mortality risk 3

Prognostic Tools (Use Within First 24-48 Hours)

• APACHE II score ≥8 predicts severe disease 1, 2
• Clinical impression of severity and obesity in the first 24 hours 3
• C-reactive protein >150 mg/L after 48 hours 3
• Glasgow score ≥3 after 48 hours 3

ICU Admission

Admit patients with organ failure to an intensive care unit whenever possible 3

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Treatment Approach

Mild Acute Pancreatitis

• Regular diet with advancement as tolerated 2
• Oral pain medications 2
• Routine vital signs monitoring 2

Moderately Severe Acute Pancreatitis

• Enteral nutrition if prolonged bowel rest needed 2
• IV pain medications 2
• IV fluids to maintain hydration 2
• Monitor hematocrit, blood urea nitrogen, and creatinine 2

Severe Acute Pancreatitis

Begin with pain control, aggressive IV fluid resuscitation, and bowel rest in the first 48-72 hours 5

• If nutritional support is required, use enteral nutrition via nasogastric route (effective in 80% of cases) rather than parenteral nutrition, as it reduces mortality, multiorgan failure, local complications, and systemic infections 3, 2, 5
• Mechanical ventilation if needed 2
• Organ support as required 2

Antibiotic Use

Do NOT use routine prophylactic antibiotics for all patients with acute pancreatitis 2

• The evidence for prophylactic antibiotics in pancreatic necrosis is conflicting with no consensus 3
• If prophylactic antibiotics are used, limit to maximum 14 days 3
• For infected pancreatitis without MDR organisms, use Meropenem, Doripenem, or Imipenem/cilastatin 2
• In severe cases with >30% necrosis, imipenem/cilastatin decreases pancreatic infection risk 5

Gallstone Pancreatitis Management

Perform urgent ERCP within 72 hours in patients with acute biliary pancreatitis who have: 3, 2

• Common bile duct obstruction
• Cholangitis
• Jaundice
• Dilated common bile duct
• Predicted or actual severe pancreatitis

Perform early cholecystectomy to decrease hospital length of stay and complication rates 5

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Monitoring and Follow-up

• Close monitoring in the first 48-72 hours is essential to prevent morbidity and mortality from worsening pancreatitis 5
• Obtain CT scan for patients with persistent organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission 3
• Overall mortality should be <10%, and <30% in severe disease 2