Rosen & Barkin's 5-Minute Emergency Medicine Consult (507 page)

• Lipase:
  
  • Rises within 4–8 hr of pain onset
    
  • More reliable indicator of pancreatitis than amylase
    
• Amylase:
  
  • Rises within 6 hr of pain onset
    
  • Levels >3 times limit of normal suggest pancreatitis.
    
  • Levels >1,000 IU suggest biliary pancreatitis.
    
  • May be normal during acute inflammation due to significant pancreatic destruction
    
  • Secreted from various sources
    
• Electrolyte, BUN, creatinine, glucose:
  
  • Hypokalemia occurs with extensive fluid losses.
    
  • Hyperglycemia
    
• CBC:
  
  • Increased hematocrit with fluid losses
    
  • Hematocrit >47% at risk for pancreatic necrosis
    
  • Decreased hematocrit with retroperitoneal hemorrhage
    
  • WBC count >12,000 unusual
    
• Calcium/magnesium:
  
  • Hypocalcemia indicates significant pancreatic injury.
    
  • Hypomagnesemia occurs with underlying alcohol abuse.
    
• Liver function tests:
  
  • Useful for prognostic indicators if suspected biliary cause
    
• CRP:
  
  • Useful to measure severity at 24–48 hr after symptoms onset
    
• Pregnancy test
  
• Arterial blood gases:
  
  • Indicated if hypoxic (assess PO
    ₂
    ) or toxic appearing (assess base deficit)
    
• ECG:
  
  • Assess electrolyte imbalances, ischemia
    

• Abdominal series radiograph:
  
  • Excludes free air
    
  • May visualize pancreatic calcifications
    
  • Most common finding is isolated dilated bowel loop (sentinel loop) near pancreas.
    
• Chest radiograph:
  
  • Pleural effusion
    
  • Atelectasis
    
  • Infiltrate
    
• US:
  
  • Useful if gallstone pancreatitis suspected
    
• Abdominal CT indications:
  
  • High-risk pancreatitis (>3 Ranson criteria)
    
  • Hemorrhagic pancreatitis
    
  • Suspicion for pseudocyst
    
  • Diagnosis in doubt
    

Endoscopic retrograde cholangiopancreatography (ERCP):

• Indicated for severe pancreatitis with cholangitis or biliary obstruction
  

• Mesenteric ischemia/infraction
  
• Myocardial infarction
  
• Biliary colic
  
• Intestinal obstruction
  
• Perforated ulcer
  
• Pneumonia
  
• Ruptured aortic aneurysm
  
• Ectopic pregnancy
  

TREATMENT

• Initiate IV access in cooperative patients.
  
• Apply cardiac monitor.
  

• ABCs
  
• Supplemental oxygen
  
• Cardiac monitor
  
• IV fluids
  

• Airway management:
  
  • Pulmonary complaints necessitate supplemental oxygen.
    
  • Endotracheal intubation for adult respiratory distress syndrome or severe encephalopathy
    
• Fluid resuscitation:
  
  • Large fluid volumes (up to 5–6 L in 1st 24 hr) to compensate for fluid losses
    
  • Continuously assess vitals, urine output, and electrolytes to ensure rapid and adequate replacement of intravascular volume.
    
• Correct electrolyte abnormalities if present:
  
  • Hypocalcemia (Calcium gluconate)
    
  • Hypokalemia occurs with extensive fluid losses.
    
  • Hypomagnesemia occurs with underlying alcohol abuse.
    
• Blood products:
  
  • In hemorrhagic pancreatitis, transfuse to hematocrit level of 30%.
    
  • Fresh-frozen plasma and platelets if coagulopathic and bleeding
    
• Analgesia:
  
  • Opiate analgesia is the drug of choice.
    
• Nasogastric suction:
  
  • Not useful in cases of mild pancreatitis
    
  • Beneficial in severe pancreatitis or intractable vomiting
    
• Antiemetics
  
• Antibiotics:
  
  • Indicated if pancreatic necrosis >30% on abdominal CT
    

Consider central venous pressure monitoring when fluid overload is a concern.

Analgesics, antiemetics:

• Morphine 2–4 mg IV
  
• Hydromorphone (Dilaudid) 1 mg IV/IM
  
• Ondansetron 4 mg IV/IM/PO
  

Electrolyte replacement, antibiotics:

• Potassium chloride: 10 mEq/h IV over 1 hr
  
• Calcium gluconate 10%: 10 mL IV over 15–20 min
  
• Magnesium sulfate: 2 g IV piggyback
  
• Imipenem: 500 mg IV q6h
  

FOLLOW-UP

• Acute pancreatitis with significant pain, nausea, vomiting
  
• ICU admission for hemorrhagic/necrotizing pancreatitis
  

• Mild acute pancreatitis without evidence of biliary tract disease and able to tolerate oral fluids
  
• Chronic pancreatitis with minimal abdominal pain and able to tolerate oral fluids
  

• Surgical/GI consultation for ERCP in severe pancreatitis with cholangitis or biliary obstruction
  
• Emergent surgical consultation mandatory in cases of suspected ruptured pseudocyst or pseudocyst hemorrhage, as definitive treatment is emergent laparotomy
  

All discharged mild pancreatitis should have scheduled follow-up within 24–28 hr.

• Gallstones and alcohol account for etiologies of 75–80% of acute pancreatitis.
  
• Early aggressive fluid therapy is essential to replace large volume losses.
  
• Nasogastric suction is not beneficial in routine pancreatitis.
  
• Consider early CT of abdomen when diagnosis in doubt or patient appears ill by clinical scoring scale (Ranson criteria ≥3).
  

• Carroll JK,Herrick B, GipsonT, et al. Acute pancreatitis: Diagnosis, prognosis, and treatment.
  Am Fam Physician.
  2007;75(10):1513–1520.
  
• Forsmark CE, Baillie J, AGA Institute Clinical Practice and Economics Committee, et al. AGA Institute technical review on acute pancreatitis.
  Gastroenterology.
  2007;132(5):2022–2044.
  
• Frossard D, Steer ML, Pastor CM. Acute pancreatitis.
  Lancet
  . 2008;371:143–152.
  
• Heinrich S, Schäfer M, Rousson V, et al. Evidence-based treatment of acute pancreatitis: A look at established paradigm.
  Ann Surg
  . 2006;243(2):154–168.
  
• Whitcomb D. Acute pancreatitis.
  N Engl J Med.
  2006;354:2142–2150.
  

See Also (Topic, Algorithm, Electronic Media Element)

CODES

• 577.0 Acute pancreatitis
  
• 577.1 Chronic pancreatitis
  
• 577.2 Cyst and pseudocyst of pancreas
  

BASICS

• Characteristic, acute episodes of physical symptoms and intense fear that rapidly peak within 10 min and resolve in∼20 min
  
• There may be a nonfearful variant in medical patients.
  

• Recurrent, unexpected panic attacks with ≥1 mo of persistence:
  
  • Concerns about having another attack
    
  • Worry about the implications or consequences of the attacks
    
  • Behavioral change, such as phobic avoidance, related to the attacks
    
  • With or without agoraphobia = anxiety related to fear of escape
    
• Episodic, recurrent, or chronic attacks
  
• Frequently comorbid with depression, substance abuse, disability, suicidal tendency