ACUTE

PANCREATITIS
Jeo thomas
MSc nursing 1st year

Sarvodaya college of nursing bangalore

OUTLINE

 Diagnosis
 Etiology
 Assessing severity
 Treatment
 Complications
CASE

 64 yr woman develops upper abd

pain late last night.Band-like with
radiation to back. Initially not
severe, but awoke and had
several episodes of non-bloody
emesis. No F/C, no dark urine
 The first 8 hours in ED/Hospital
needs 36 mg MSO4 to control
pain.
CASE
 BP: 94/45 
160/90, HR: 76, T:
 PMHx: HTN, 97.9,
Hyperlipidemia  GEN: awake alert
 PSurgHx: TAH-  HEENT: no icterus,
BSO mouth is dry
 MEDS: Estrace,  CARDIO: RRR
Plendil  ABD: SNT, no
rebound, no
 SOCIAL: no bruising
tobacco or
ETOH
CASE
 ABDMOMEN  LABS:
CT: marked  AST/ALT both
peripancreatic slightly
fluid, streaking elevated.
around
pancreas, normal
 T.bili normal
enhancement, no  Amylase 2620
clear gallstones,  lipase 26,625
CBD not dilated  Hct normal
 WBC 14.8
 MORTALITY

 Mild Acute Pancreatitis

 < 5%
 Severe Acute Pancreatitis
 25%

 Nearly 20% of all pts with AP

develop SAP
 25% of SAP pts die
DISEASE COURSE

 Deaths occur in 2 phases:

 PHASE 1 (with in first few days):
 SIRS
 ARDS

 PHASE 2 (after second week):

 Sterile necrosis
 Infected necrosis

 Multiple organ dysfunction

DIAGNOSIS
 FAIRLY SUDDEN ONSET UPPER ABD
PAIN
 RADIATION TO BACK
 N/V

 ELEVATED AMYLASE
 ELEVATED LIPASE
 CULLEN SIGN (PERIUMBILICAL
BRUISING)
 GREY-TURNER SIGN (FLANK BRUISING)
CAUSES

 The Big Three:

 Gall Stones (40%)

 Alcohol (35%)
 Idiopathic (20%)
CAUSES
 The Others:
 Trauma (pancreatic duct injury)
 Post-ERCP

 Drugs (rare)
 30 meds identified
 Azathioprine (Imuran – immune suppressant)
 Valproic acid (Depakote – seizures/mood
stabilizer)
 Didanosine (Videx – HIV med)
 Pentamidine (HIV – pneumocystis carinii Tx)
 Mesalamine (Asacol – ulcerative colitis Tx)
CAUSES
 Organ transplant, major surgery
 Hypertryglycerides (rare)
 Greater than 1000 mg/dL
 Pregnancy
 Third trimester until 6 weeks post partum
 HIV
 35 to 800 times greater risk of AP c/w
general pop.
 Hypercalcemia
 Most often secondary to hyperparathyroidism
 Scorpion, spider, and Gila Monster lizard
bites
PREDICTING CAUSES

 Gallstones:
 ALT > 150 IU/dL  PPV >95%
 Ultrasound will see gallstones in 60-
80% of cases
 (Less reliable for stones in CBD)

 MRCP sensitivity 90-100%

 ETOH
 Lipase > amylase
SEVERITY

 Early identification of severity and

appropriate ICU care has
significantly reduced mortality over
the last 20 yrs

 Bedside eval (compared to

severity scoring) missed over 50%
of severe cases
SEVERITY
 When do you do “early” transfer to ICU?
 When do you consult critical care team?
 When do you start antibiotics?
 When do you get a CT scan?
 “They” say people crash fast – who are
these people?
 What is “aggressive fluid resuscitation?”
SEVERITY

 APACHE II
 Best test
 Can be done at 24 hrs, can be repeated
 Ranson’s Criteria (1974!)
 Needs to be done at 24 and 48 hrs
 Balthazar’s (CT scan criteria)
 Glascow
 Single Markers of Severity
Ranson’s Criteria
≥ 3 is severe
SINGLE MARKER’S
CASE

 At 36 hrs you are night float and

get a call from RN. Pt with
increased work at breathing,
crackles at bases of lungs. She
is 4 liters ahead on fluids.

 What do you want to do?

TREATMENT

 “Vigorous intravenous hydration

alone is the best available
option in the prevention of
pancreatic necrosis.”

 Pitchhumoni et al. “Mortality in Acute

Pancreatitis,” Journal of Clinical
Gastroenterology
TREATMENT

 AGGRESSIVE FLUID
RESUSCITATION
 May require 250-500 cc/hr for first 48 hrs
 6 L of fluid is sequestered in abdomen alone
 Third spacing can consume up to 1/3 of total
plasma volume
 1/3 of people die in the first phase 
50% of these are associated to ARDS

 PULMONARY EDEMA ≠ CHF

TREATMENT

 INFLAMMATORY MEDIATORS &

PANCREATIC SECRETIONS
ARE WASHING THROUGH THE
LUNGS

 INCREASED PULM. VASCULAR

PERMEABILITY  PULMONARY
EDEMA
TREATMENT

 How do you know you are

resuscitated?
 Blood pressure
 Heart rate

 Urine output

 SPO2/ABG’s show good

oxygenation and no acidemia
TREATMENT
 AGGRESSIVE FLUID RESSUCITATION
 You may create electrolyte imbalances that
need to be corrected
 You may need CVP monitoring (central line)
 CXRs help (CHF vs ARDS)
 ABGs help (still hypoxic  need more fluids?)

 23% of SAP pts get ARF  80% mortality

 0.5 cc/kg/hr urine output is goal (need a

Foley)
TREATMENT

 OXYGENATE
 Give O2 (spO2≥95%)
 Liberal intubation/ventilation to
treat ARDS

 SCDs
NECROSIS

 Starts to occur within 4 days of

disease
 CT with po & IV contrast is gold
standard
 Necrotic areas do not enhance
 You will NOT see it on CT before 48hrs

 Once you Dx necrosis mortality jumps

 40-60% get secondary infection
 Mortality then approaches 80%
SECONDARY INFECTIONS

 SYMPTOMS:
 N/V, epigastric pain, distension, fever,
elevated WBC
 Diagnosis of sterile vs infected
necrosis
 CT-guided needle aspiration
 This is the most devastating
complication and marks the second
peak in mortality (@ 2 weeks)
SECONDARY INFECTIONS

 FLUID COLLECTIONS
 PSEUDOCYSTS
 PANCREATIC NECROSIS

 Above get infected in 1-10% of

all acute pancreatitis, but are
source of 80% of deaths
SECONDARY INFECTIONS

 What bugs?
 Gram (-) bacteria cross from gut
 E. coli (35%)
 Klebsiella (24%)

 Enterococcus (24%)

 Staph (14%)

 Pseudomonas, proteus, strep,

enterobacter, bacteroides,
anaerobes
SECONDARY INFECTIONS

 Pathogens colonize gut

 Intestinal mucosal barrier breaks
down
 Bacteria crosses through
ANTIOBIOTICS

 Controversial
 They DO decrease incidence of
infection in necrosis, but do NOT
decrease mortality
 Gotta cover multiple bugs
 Gotta get into pancreas

 If you see necrosis  start

antibiotics (?)
ANTIOBIOTICS

 Imipenem

 Cipro + metronidazole

 One study showed 24% of pts

had fungus
 Very poor prognosis
NUTRITION

 Normal pancreas secretes up to 2

liters/day of secretions
 Pancreatic stimulation during AP
releases proteolytic enzymes 
autodigestion
 Oral feeding increases release of
secretin and cholecystokinin 
stim pancreas
 “rest the pancreas”  “NPO”
NUTRITION

 TRADITION:

 Rest the pancreas  NPO

 TPN only after 5-7 days (prevent
starvation)
 Ill pts can’t be fed (ileus,
aspiration)
NUTRITION

 ENTERAL vs TPN Feedings:

 If distal to Ligament of Treitz
(nasojejunal tube or J-tube) pancreatic
secretion = basal rate
 Both started after 48 hours
 Easier to restart po feedings
 Average length of nutritional support
shorter
 7 vs 11 days
 Fewer septic complications
 $23/day vs $222/day
NUTRITION
 NEW THOUGHTS
 Meta-analysis of 15 randomized
studies:
 Compared early vs delayed ENTERAL
feedings in 753 critically ill pts
 Early was 36 hrs!
 Improved:
 Wound healing
 Host immune function
 Preservation of intestinal mucosal integrity
 Decreased infections
 BUT, no decreased mortality
NUTRITION

 Feed to maintain gut integrity

 Protects against transfer of

bacteria
ERCP

 If there is a stone or cholangitis

(biliary sepsis) or persistent
jaundice
 Need urgent ERCP with
sphincterotomy and stone
extraction

 Otherwise, ERCP not indicated

SURGERY
 Used to be very liberal with early
surgery
 Trauma
 If duct damaged
 Gallstone etiology and mild
 Cholecystectomy in same admission
 If no chole  25-69% recurrence rate
of pancreatitis within 6-18 wks
 Sterile necrosis  controversial
 Infected necrosis  yes, but delay
CASE REVISITED
 By 48 hours pt’s abd pain is worsening
 HR is 140, afebrile, BP normal
 Abd shows very subtle guarding
 WBC: 27.6
 Ca++: 6.6
 PO2: 61
 Base deficit: 8
 BUN rise: 9
 LDH: 976
 RANSON SCORE: 3
 APACHE II SCORE: 8
“THANK YOU”