Urgent Care RAP
Urgent Care RAP
Hippo Education LLC.,
What Do I Do Next? | Pancreatitis
21 minutes Posted Oct 16, 2020 at 5:04 pm.
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This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD

Matthieu DeClerck, MD, Mike Weinstock, MD, and Cameron Berg, MD sit down to discuss the diagnostic criteria for acute pancreatitis. They discuss workup: the role of imaging to rule out gallstone pancreatitis. They go into risk stratification of acute pancreatitis as well as Initial management: pain control, IV fluids, nutrition. And ultimate disposition – when to go home? When to admit to a higher level of care?

 

Pearls:

  • Confirmatory CT scanning is rarely needed to confirm pancreatitis
  • Amylase level is neither as sensitive or specific as lipase.
  • Early feeding, has been shown to improve outcomes in patients with pancreatitis.

DIAGNOSING PANCREATITIS

  • Must meet 2 of the following 3 criteria:
    • Clinical presentation that is consistent with pancreatitis - epigastric or upper abdominal pain, frequently radiating to the back often with associated with nausea and vomiting,
    • A lipase level that is three times the upper lab limit of normal for a given assay.
      • Do not order an amylase as it not as sensitive or specific for pancreatitis as lipase.
      • The initial lipase level cannot predict outcomes of patients with pancreatitis and there's no utility in trending lipase levels
    • A CT scan demonstrating pancreatic inflammation consistent with pancreatitis.
      • Note: A CT is rarely needed to confirm pancreatitis but it is the gold standard when there is diagnostic uncertainty.
  • Perform a RUQ ultrasound to rule out gallstone pancreatitis as the most common cause of pancreatitis in the United States is biliary.
    • Patients with biliary tract obstruction will need an ERCP or MRCP urgently that many facilities cannot get 24/7.
  • Obtain a triglyceride level as hypertriglyceridemia is the third most common cause of pancreatitis after alcohol and gallstones.

MANAGEMENT

  • Not all patients with acute pancreatitis require hospital stay.
  • Consider the following factors before deciding on admission:
    • Patient vital signs
    • Clinical appearance
    • Ability to perform ADLs
    • Presences or absence of markers of end organ stability
  • Patients with pancreatitis who are admitted should receive adequate fluid resuscitation in the form of 2-3L  of IV crystalloid.
  • Feed the patient orally as soon as possible as early enteral nutrition, rather than bowel rest, has been shown to greatly increase recovery.
  • Patients with gallstone pancreatitis and pancreatitis secondary to hypertriglyceridemia require a higher level of care and should be referred appropriately.

REFERENCES:

  1. Uhl, W. et al. 2003. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology.
  2. Tenner, S. 2013. American College of Gastroenterology Guidelines: Management of Pancreatitis. The American Journal of Gastroenterology.