Acute Pancreatitis
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Acute inflammation of the pancreas
Cause
- Excessive alcohol intake
- Gall stones, biliary tract disease (obstructive cancer or anatomical abnormalities)
- Infections, e.g. mumps, HIV, hepatitis A, ascaris
- Drugs, e.g. sulphonamides, furosemide, lamivudine, analgesics, organosphosphate poisoning
- Peptic/duodenal ulcers
Clinical features
- Acute abdominal pain usually in the epigastrium radiating to the back
- Pain worsened by eating or lying down and relieved by sitting up or leaning forward
- Nausea, vomiting, abdominal distension
- Fever, tachycardia, dehydration (may be severely ill with shock)
- Abdomen is very tender but in the absence of peritonitis there is no rigidity/rebound tenderness
Complications
- Pseudocysts
- Necrotizing pancreatitis with infection
- Peritonitis
Differential diagnosis
- Perforated peptic ulcer, peritonitis
- Acute cholecystitis, inflammation of the biliary tract
- Sickle-cell anaemia crisis
Investigations
- Blood: Serum analysis, complete blood count, random blood sugar
- Raised pancreatic amylase and lipase > 3 times normal
- Ultrasound: gallstones, pancreatic oedema, abdominal fluid
- Liver function tests: raised liver enzymes
ManagementTreatment
Mild acute pancreatitis
(No organ failure, no local or systematic complications, no signs of peritonitis, normal serum creatinine, normal haematocrit [not increased]
Early aggressive fluid resuscitation and acid-base balance
- Prevent volume depletion (adequate fluids with Ringer’s Lactate). Give 5-10 ml/kg/hour or 250-500 ml of isotonic crystalloids in the first 12-24 hours or urine output of at least 0.5 ml/kg/hour
- Give IV fluids to correct metabolic and electrolyte disturbances and to prevent hypovolaemia and hypotension
- Monitor electrolytes
- Goal is to decrease haematocrit and BUN in 48 hours, evaluate every 4-6 hours
Pain control
- Opioids, paracetamol, epidural anaesthesia [avoid NSAIDs)
- Rectal/IV paracetamol 500 mg 6-8 hourly
- or Pethidine 25-100 mg SC or IM or 25-50 mg slow Repeat prn every 4-6 hours
- IV morphine 1-3 mg every 4 hours
- Be aware of complications e.g. constipation, dysphagia, respiratory depression, confusion
Emesis
- Anti-emetics as appropriate
- Metoclopramide 10 mg IV/IM every 8 hours
- Pass a nasogastric tube for suction when persistent vomiting or ileus occurs
Feeding and nutrition
- No feeding by mouth until signs and symptoms of acute inflammation subside (i.e. cessation of abdominal tenderness and pain, return of hunger and well-being)
- Provide energy with dextrose 50% 300-500 ml a day (add 50 ml to 500 ml Normal saline) to prevent muscle wasting
- Start early oral re-feeding on demand, start within 48-72 hours as soon as the patient is able and can tolerate feeds
- Start with clear liquids, then low fat semi-solid feeds then a normal diet – according to tolerance
- Monitor daily for vital signs, fluid intake, urinary output, and GI symptoms
- If oral feeding not possible, consider peripheral parenteral and central parenteral nutrition
Glycaemic control (hyperglycaemia is common)
- Keep serum blood sugar between 6-9 mmol/l
- Avoid hypoglycemia
Antibiotics
- Avoid inappropriate use of antibiotics and other medications e.g for prophylaxis
- In case of specific infection, e.g. biliary sepsis, pulmonary infection, or UTI, treat vigorously with appropriate antibiotic therapy
Other measures
- Address the underlying cause as is appropriate
- Stop alcohol or drugs
- Mobilisation
- Evaluation for gallstones by ultrasound scans
- Manage complications e.g. acute peri-pancreatic fluid collections, acute necrosis, pseudocyst
Moderately acute pancreatitis
- Transient organ failure (< 48 hours)
- Local or systematic complications without persistent organ failure
Severe acute pancreatitis
- Persistent organ failure (> 48 hours)
- Either single or multiple organ failure
Treatment as above plus
- Refer or consult with specialist at higher level
- HDU/ICU ( monitoring and nursing)
- Volume resuscitation
- Pain management
- Nutrition/ re-feeding
- Glycaemic control
- Nasogastric tube
- Oxygen / mechanical ventilation
- Renal replacement
- Address the cause where possible
- Manage complications as appropriate e.g. acute peri-pancreatic fluid collection, acute necrosis, pseudocyst
Note: Look out for diabetes mellitus as a consequence of damage to the pancreas
Prevention
- Reduce alcohol intake - moderate consumption
- Limit use of toxic drugs