Acute Pancreatitis Diagnosis and Management
Clinical Presentation
- Fever, particularly moderate grade fever, is commonly seen in necrotizing acute pancreatitis, and a sudden high fever may indicate development of infection, although this can arise from sources other than the pancreatic area 1
- Epigastric or diffuse abdominal tenderness is commonly found, and occasionally, body wall ecchymoses may be present (Cullen's sign at the umbilicus, Grey-Turner's sign in the flanks) 2
- Signs of cardio-respiratory or renal failure may indicate septic complications 1
Laboratory Findings
- Elevated serum lipase (greater than twice the upper limit of normal) or amylase (four times above normal) is indicative of acute pancreatitis 2, 3
- Increased white blood cell count, elevated C-reactive protein (CRP), and procalcitonin (PCT) are also associated with acute pancreatitis, with PCT being the most sensitive laboratory test for detection of pancreatic infection 3
- Other tests may show deranged clotting, increased APACHE II score, and biochemical features of multiple organ failure in severe cases 1
Imaging Findings
- Ultrasound may show a swollen pancreas, though the gland is poorly visualized in 25-50% of cases 4
- CT scan with IV contrast is the gold standard imaging modality, and MRI can also be used as an alternative to CT 3, 1
- Chest x-ray may show pleural effusions or features of acute respiratory distress syndrome (ARDS) in severe cases 1
Classification of Severity
- Mild acute pancreatitis is characterized by minimal organ dysfunction with uneventful recovery, and the predominant pathological feature is interstitial edema of the gland 5
- Moderately severe acute pancreatitis is associated with transient (less than 48h) organ failure, and local complications or exacerbation of co-morbid disease 6
- Severe acute pancreatitis is characterized by persistent (more than 48h) organ failure, and is associated with organ failure and/or local complications such as necrosis (with infection), pseudocyst, or abscess 5, 6
Treatment Approach
- Routine prophylactic antibiotics are not recommended for all patients with acute pancreatitis, but are indicated only for confirmed infections or when there are signs of systemic infection 3
- When indicated, imipenem has been recommended based on studies of antibiotic penetration into pancreatic tissue 1
- Endoscopic retrograde cholangiopancreatography (ERCP) is indicated in gallstone pancreatitis with cholangitis or common bile duct obstruction 3, 7
Monitoring and Supportive Care
- All cases of severe acute pancreatitis should be managed in a high-dependency unit (HDU) or intensive therapy unit (ITU) setting 7
- Regular monitoring of vital signs, including pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature is essential 8
- Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 8