Acute Pancreatitis

Educational Objectives

The goal of this program is to improve acute pancreatitis. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate between various types of pancreatitis.
2. Implement recommendations for the use of various agents and techniques in the treatment of acute pancreatitis.

Summary

Etiology of pancreatitis: ≈80% of cases are caused by alcohol use or gallstones; 10% to 15% are idiopathic; can be autoimmune; it is immunoglobulin-G4-related disease (type 1 and type 2; type 1 is common in elderly patients; type 2 is correlated with inflammatory bowel disease, colitis, and Crohn disease); iatrogenic pancreatitis occurs after endoscopic retrograde cholangiopancreatography or endoscopic ultrasound-guided fine needle biopsy (aspiration of the pancreas); 10% of pancreatic cancers present with acute pancreatitis (AP); neoplastic cysts (eg, main duct intraductal papillary mucinous neoplasm [IPMN], side branch IPMN) cause AP in 20% to 25% of cases; if computed tomography (CT) shows a cyst in the pancreas of a patient presenting to the emergency department, the possibility of neoplasm should be ruled out; probability of structural, post-traumatic, and vascular causes is low

Diagnosis of AP: patients must satisfy 2 of 3 criteria, including typical pancreatic-type upper abdominal pain or diffuse pain radiating toward the spine, amylase or lipase levels 3-fold higher than the upper limit of normal, and evidence of pancreatic or peripancreatic inflammation on CT, ultrasonography, or magnetic resonance imaging (MRI); amylase and lipase have less than optimal sensitivity and high specificity; mild cases are interstitial pancreatitis (the parenchyma remains intact); life-threatening AP is usually necrotizing; mortality rate is <1% for interstitial pancreatitis, ≈10% for sterile necrotizing pancreatitis (NP), and 25% for infected NP; mortality is related to multiorgan failure early in the disease and infection later in the progression

Criteria to assess the severity of pancreatitis: the systemic inflammatory response syndrome (SIRS) criteria and blood urea nitrogen, impaired mental status, SIRS criteria, age, and pleural effusion (BISAP) score are most frequently used; the higher the BISAP, the higher the mortality; severe AP is defined as persistent single or multiple organ failure as defined by the modified Marshall scoring system lasting >48 hr

Management of AP: volume is key; volume resuscitation maintains the perfusion of the pancreatic microcirculation and intestine, and prevents intestinal ischemia and subsequent bacterial translocation, thereby reducing risk for infection and associated morbidity and mortality; several studies determined lactated Ringer’s injection significantly reduced SIRS and C-reactive protein at 24 hr compared with normal saline; recommended rate of fluid expansion is 5 to 10 mL/kg per hr; for the first 24 hr, ≤4 L (average of 2.5-4 L) is recommended for the average adult; heart rate, mean arterial pressure, urinary output, or hematocrit can guide resuscitation

Role of CT: CT performed in the first 48 hr has low sensitivity for detecting necrosis; consider CT if the patient worsens over several days or if the diagnosis is uncertain

Infection: routes of infection are multifocal; studies have shown that use of prophylactic antibiotics does not decrease morbidity or mortality

Nutrition: enteral nutrition reduces morbidity and mortality; the nasogastric approach is acceptable if the patient does not have nausea or vomiting; enteral nutrition reduces infection, organ failure, hospital stay, the need for surgical intervention, and mortality; studies have shown enteral nutrition is associated with greater reduction in morbidity and mortality compared with parenteral nutrition; a low-fat diet is recommended in patients with mild AP with no nausea or vomiting, passing flatus, and who feel hungry; if moderately severe to severe AP is present, or if the patient shows gastrointestinal symptoms, initiate enteral nutrition within 24 to 72 hr

Diagnosis of infected NP: criteria are clinical signs and symptoms and imaging findings (gas may be seen in the peripancreatic collections, but absence of gas does not exclude infection); gas is present in only 15% to 20% of infected necrosis; rule out other sources of infection (eg, central line, urine, lung)

Biliary pancreatitis: because of high recurrence rate, cholecystectomy is recommended even in mild cases

Idiopathic pancreatitis: requires evaluation by a gastroenterologist; a cause can be identified in 50% of cases; 2% to 5% show neoplastic changes

Terminology of fluid collections: according to the revised Atlanta classification for AP, in patients with interstitial pancreatitis with intact parenchyma, fluid collection during the first 4 wk is acute peripancreatic fluid collection; after 4 wk, if fluid collection matures, the pancreas is still intact, and the collection has a wall of fibrous tissue, it is called a pseudocyst; with NP, the collection in the first 4 wk is heterogeneous and is called acute necrotic collection; after 4 wk, it becomes encapsulated and more defined and is termed walled-off necrosis; the parameters to describe pancreatic fluid collections include duration (eg, <4 wk, >4 wk), appearance of the wall, (eg, mature vs free-floating fluid), content of the fluid collection, location (eg, pancreatic, peripancreatic), and presence of infection; 60% of the time, the fluid-only collections resolve spontaneously and are easily drained if they become symptomatic; with NP, collections are unlikely to resolve on their own; if symptomatic, drainage and debridement is needed

Determination of collection content: CT is a poor predictor of collection content; consider the chronology; obtain MRI or endoscopic ultrasonography to assess the content; pancreatic vs peripancreatic location is important as it influences morbidity and mortality

Management of severe AP: nutrition is most important and starts with enteral feeding; if there is no improvement over the next few weeks, consider a percutaneous endoscopic gastrostomy tube or a direct, surgically placed jejunostomy tube; according to a paper published in the New England Journal of Medicine in 2010, the current standard of care involves a step-up approach; in a patient with infected NP, start with endoscopy; can combine with percutaneous approach if there is extension of fluid into the paracolic gutters; step-up approach — superior compared with minimally invasive surgery in terms of shorter hospital stay and lower risk for pancreaticocutaneous fistula with similar mortality; percutaneous approach — appropriate in some situations, especially if fluid extends into the paracolic area or if performing step-up with a video-assisted retroperitoneal debridement approach, but intervention is initially limited to endoscopy in most cases; lumen-apposing metal stents — can be deployed under endoscopic ultrasonography; they are available in different sizes (10-20 mm diameter); complication rate is 10% to 15% and includes bleeding, perforation, and, rarely, gas embolism

Readings

Chen H, Lu X, Xu B, et al. Lactated ringer solution is superior to normal saline solution in managing acute pancreatitis. Journal of Clinical Gastroenterology. 2021;Publish Ahead of Print. doi:10.1097/mcg.0000000000001656; Colvin SD, Smith EN, Morgan DE, et al. Acute pancreatitis: an update on the revised Atlanta classification. Abdominal Radiology. 2019;45(5):1222-1231. doi:10.1007/s00261-019-02214-w; Dutta AK, Goel A, Kirubakaran R, et al. Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis. Cochrane Database of Systematic Reviews. 2020. doi:10.1002/14651858.cd010582.pub2; Garber A, Frakes C, Arora Z, et al. Mechanisms and management of acute pancreatitis. Gastroenterology Research and Practice. 2018;2018:1-8. doi:10.1155/2018/6218798; Gardner TB. Fluid resuscitation in acute pancreatitis — going over the waterfall. New England Journal of Medicine. 2022;387(11):1038-1039. doi:10.1056/nejme2209132; Heckler M, Hackert T, Hu K, et al. Severe acute pancreatitis: surgical indications and treatment. Langenbeck’s Archives of Surgery. Published online September 10, 2020. doi:10.1007/s00423-020-01944-6; Kiriyama S, Gabata T, Takada T, et al. New diagnostic criteria of acute pancreatitis. Journal of Hepato-Biliary-Pancreatic Sciences. 2009;17(1):24-36. doi:10.1007/s00534-009-0214-3; Mederos MA, Reber HA, Girgis MD. Acute pancreatitis. JAMA. 2021;325(4):382. doi:10.1001/jama.2020.20317; Song J, Zhong Y, Lu X, et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: A systematic review and meta-analysis. Medicine. 2018;97(34):e11871. doi:10.1097/MD.0000000000011871; Yuan X, Xu B, Wong M, et al. The safety, feasibility, and cost-effectiveness of early laparoscopic cholecystectomy for patients with mild acute biliary pancreatitis: A meta-analysis. The Surgeon. Published online July 2020. doi:10.1016/j.surge.2020.06.014.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Chahal is a consultant for Boston Scientific and Medtronic and is a member of the advisory council for Medtronic. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Chahal was recorded at Hospital Medicine 2022, held on October 8–9, 2022, in Pittsburgh, PA, and presented by the Cleveland Clinic Foundation. For information about CME activities from this presenter, please visit https://www.clevelandclinicmeded.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

IM700302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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