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