What are the next steps for a patient with a swollen pancreas and increased bloating?

Management of Swollen Pancreas with Increased Bloating

The immediate priority is to confirm the diagnosis of acute pancreatitis within 48 hours and stratify severity to determine if intensive care management is required, as missing a severe attack or alternative life-threatening condition can result in potentially avoidable deaths. 1, 2

Initial Diagnostic Confirmation

• Diagnose acute pancreatitis when two of three criteria are present: upper abdominal pain, serum amylase/lipase ≥3× upper limit of normal, and/or characteristic imaging findings 3, 4
• Obtain serum amylase, lipase, full blood count, renal and liver function tests, glucose, calcium, and transabdominal ultrasound immediately 4
• Ultrasound is recommended initially in all patients despite visualizing the pancreas poorly in 25-50% of cases, but it effectively detects gallstones, bile duct dilatation, free peritoneal fluid, and alternative pathology like abdominal aortic aneurysm 1
• If clinical and biochemical findings are inconclusive after initial workup, obtain a CT scan for definitive diagnosis 1, 2

Severity Stratification (Critical Within 48 Hours)

Clinical assessment alone misclassifies approximately 50% of patients, so objective criteria must be used: 1, 5

• Check for organ failure (pulmonary, circulatory, or renal insufficiency) clinically, which automatically indicates severe disease 1
• Apply Glasgow or Ranson scoring systems over the first 48 hours—three or more positive criteria constitutes severe disease with 70-80% accuracy 1
• Elevated hematocrit, blood urea nitrogen, or creatinine should prompt immediate intensive resuscitation measures 6
• Obtain dynamic contrast-enhanced CT scanning within 3-10 days of admission using non-ionic contrast to assess pancreatic necrosis and complications 1

Common pitfall: Early CT within 72 hours may not show necrotic areas and underestimate severity 2, 5

Immediate Management Based on Severity

For All Patients (Mild and Severe):

• Begin aggressive intravenous crystalloid fluid resuscitation immediately—this is the cornerstone of management 6, 4
• Provide adequate analgesia for pain control 3, 4
• Institute bowel rest initially, then advance to enteral nutrition as tolerated 3, 4
• For bloating specifically, simethicone can provide symptomatic relief of gas-related pressure and bloating 7

For Severe Acute Pancreatitis:

• Transfer immediately to HDU or ITU setting with full monitoring and systems support 1
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature 1
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late clinically 1
• Consider prophylactic intravenous cefuroxime or imipenem/cilastatin if >30% necrosis is present to reduce pancreatic infection risk 1, 3

Gallstone-Specific Management (If Detected)

The presence of gallstones fundamentally changes management and requires urgent intervention in specific circumstances: 1

Severe Gallstone Pancreatitis:

• If the patient fails to improve within 48 hours despite intensive resuscitation, perform urgent ERCP with sphincterotomy 1
• If increasingly deranged liver function tests with signs of cholangitis (fever, rigors, positive blood cultures) are present, perform immediate therapeutic ERCP 1
• Always perform ERCP under antibiotic cover 1

Mild Gallstone Pancreatitis:

• Perform laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 1
• Assess common bile duct preoperatively with liver biochemistry and ultrasound 1

Nutrition Management

When prolonged bowel rest is indicated, enteral nutrition is superior to parenteral nutrition: 3

• Enteral feeding reduces death, multiorgan failure, local complications, and systemic infections compared to parenteral nutrition 3
• Reserve parenteral nutrition only when enteral access is impossible 4

Red Flags Requiring Immediate Action

• If peritoneal signs are prominent, consider alternative diagnoses including perforated viscus—occasionally acute pancreatitis and another intra-abdominal catastrophe coexist 1, 2
• If peritoneal fluid is detected without other signs of pancreatitis, sample it under radiological guidance to exclude bacterial contamination suggesting perforation 1, 2
• Misdiagnosing peritonitis in non-perforated pancreatitis as perforated viscus leads to unnecessary surgical intervention 2, 5

Follow-Up and Prevention

• Refer patients with local complications to specialist tertiary centers for potential drainage or necrosectomy 4
• Institute proactive long-term management to prevent recurrence and progression to chronic pancreatitis 4
• Address underlying etiology (gallstones, alcohol, hypertriglyceridemia, drugs) to reduce recurrence risk 4