Acute and Chronic Pancreatitis

Leave a Comment / / By / Internal Medicine Residency, PGY-3 / acute, chronic, GI, pancreatitis

In this section, I’ll outline important facts about Acute Pancreatitis and Chronic Pancreatitis that most residents and hospitalists should be aware of.

 

 

Acute Pancreatitis

  • Hospitalists, listen up!  This is the #1 GI cause of hospitalization in the States.
  • Clinically:
    • c/c severe epigastric pain
    • 80% are classified as “Mild Pancreatitis”
      • Recovery within few days
    • 20% are classified as either Moderate or Severe
      • Moderate:  pancreatic necrosis, fluid collections, and temporary organ dysfunction outside of pancreas.
      • Severe:  3+ days of organ failure, predictor of death.
        • BUN > 20 mg/dL, Hct > 44%, and elevated Creatinine are POOR PROGNOSTIC criteria.
  • Pathophysiology:
    • Capillary leak syndrome is caused by SIRS; led by premature activation of pancreatic enzymes leading to autodigestion.
    • 80% of acute pancreatitis is caused by gallstones and alcohol.
    • Remaining 20%:
      • Meds – lasix, asparaginase, didanosine, mesalamine, HCTZ, 6-MP/AZA, simvastatin.
      • Triglyceridemia (1,000 and up) and/or Hypercalcemia
      • Choledochocele
      • Post-ERCP
      • Very rarely:  viral/parasitic infection, trauma, ischemia, Celiac disease, autoimmune.
  • Diagnosis of Acute Pancreatitis:
    • Need 2/3 of the following:
      • acute epigastric pain (may radiate to back), better when leaning forward
      • serum lipase > 3x upper limit of normal
      • CT or MRI findings consistent with inflammatory process.
    • Symptomatic pleural effusion may result, due to SIRS process.
    • LFT elevation – think common bile duct obstruction.
    • A common etiology is gallstones, therefore all patients need transabdominal US.
    • CT Abdomen with contrast is NOT required for the diagnosis; it may miss some gallstones.
  • Treatment of Acute Pancreatitis:
    • IV Fluid hydration, NPO, pain control PRN, and Zofran/Phenergan PRN nausea.
      • IVF @ 250-500 mL/hr is critical in the immediate setting (12-24 hours)
    • When to begin ORAL feeding:
      • Severe pancreatitis = in 72 hours
        • This protocol actually reduces mortality, infections, and organ failure!
      • Mild-moderate = when nausea/vomiting abates.
    • AVOID TPN.
  • Acute Pancreatitis Complications:
    • Pseudocysts = persistent interstitial fluid collections (peripancreatic) with encapsulation after 4 weeks.
    • Walled-off necrosis = after 4 weeks, once necrotic tissue becomes encapsulated.
    • Most will resolves on their own.
    • Diabetes mellitus, gastric outlet obstruction, splenic vein thrombosis, colonic necrosis, gastric variceal bleeding.

Chronic Pancreatitis

  • Clinically:
    • c/c Epigastric pain with radiation to the back, waxes and wanes.
    • Consider pseudocyst or biliary/pancreatic duct stricture if constant pain.
    • Bulky/greasy stool owing to pancreatic lipase insufficiency.
    • Diabetes mellitus due to malfunction of endocrine portion of pancreas.
  • Pathophysiology:
    • Chronic inflammatory condition, usually caused by alcohol use exceeding 50-80 g/day (single drink = 14 g of alcohol)
    • Other important causes:
      • Tobacco is independent risk factor.
      • Genetic mutations of certain genes
      • Obstructive, secondary to pancreatic head tumor, intraductal mucinous neoplasm, trauma with ductal stricture.
      • Recurrent severe acute pancreatitis
      • Irradiation-induced
      • Celiac disease or autoimmune pancreatitis
      • Idiopathic
  • Diagnosis of Chronic Pancreatitis:
    • Amylase and lipase levels are typically normal
    • Typical clinical features and calcifications on abdominal imaging.
    • Supporting criteria:  bulky/greasy stools, diabetes
    • If CT abdomen cannot find calcifications of pancreas, consult GI for endoscopic US (EUS).
    • Quantitative 72-hour fecal fat testing, direct CCK or secretin stim. tests also available.
  • Treatment of Chronic Pancreatitis:
    • Educate patient:  STOP smoking.
    • Pain control with acetaminophen, ibuprofen, and tramadol.
    • Low-dose TCAs and gabapentinoids if none of above work.
    • Pancreatic enzymes, including 90,000 USP lipase with meals, half dose with snacks.
    • Endoscopic stenting of culprit ductal lesions.

Bibliography

  • ACP MKSAP 17:  Gastroenterology and Hepatology, pgs. 23-27
  • Image source:  https://en.wikipedia.org/wiki/Chronic_pancreatitis
    • CT image showing numerous calcifications within parenchyma of pancreas.

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