How should acute pancreatitis be managed?
Acute pancreatitis should be managed as a medical emergency as it is a potentially fatal condition.
Initiate fluid resuscitation as soon as this diagnosis is suspected
Simultaneously conduct diagnostics to establish the diagnosis, assess severity, and rule out potential differential diagnoses of acute abdominal pain.
List the diagnostic criteria for acute pancreatitis.
Two of the three following criteria should be met for a diagnosis of acute pancreatitis to be made.
Characteristic abdominal pain
↑ Serum pancreatic enzymes: lipase or amylase ≥ 3× ULN
Characteristic findings of acute pancreatitis on cross-sectional imaging (e.g., contrast-enhanced CT abdomen)
Which (laboratory) studies should be conducted in all patients?
Perform laboratory studies to:
Establish the diagnosis: serum lipase and/or amylase levels
Determine severity: CBC, BMP, ABG, LDH, inflammatory markers, serum calcium
Evaluate for the underlying etiology: liver chemistries, serum or plasma triglyceride levels
Obtain ultrasound abdomen.
What should be done in diagnostic uncertainty?
Perform contrast-enhanced CT (CECT) abdomen.
What should be done when diagnosis is confirmed?
Confirmed diagnosis
Perform further diagnostics as needed to determine the etiology (e.g., MRCP for suspected biliary pancreatitis).
Calculate severity scores of acute pancreatitis to estimate severity and prognosis.
In patients with severe pancreatitis, consider CECT abdomen 5–7 days after the onset of symptoms to assess for necrotizing pancreatitis.
Lab studies with respective findings (table).
What is the first-line imaging modality? What are its indications and supportive findings?
Indications: first-line imaging modality for all patients
Supportive findings
Features of acute pancreatitis (visible in 20% of cases)
Enlarged hypoechoic pancreas (pancreatic edema)
Peripancreatic fluid and/or ascites
Features of biliary pancreatitis
Cholelithiasis and/or gallbladder sludge [8]
Dilated biliary tree
Evidence of complications: pancreatic pseudocysts, walled-off necrosis (typically > 4 weeks from symptom onset)
List indications and findings of CT abdomen and pelvis with IV contrast.
Diagnostic uncertainty (e.g., typical clinical features in a patient with moderately elevated pancreatic enzymes)
Severe pancreatitis : optimally performed > 5–7 days after symptom onset
Lack of improvement (after > 7 days) or sudden acute deterioration
To evaluate for underlying etiology if routine diagnostic studies are negative
Findings
Features of acute pancreatitis
Enlargement of the pancreatic parenchyma with edema
Indistinct pancreatic margins with surrounding fat stranding
Peripancreatic free fluid
Evidence of complications
Necrotizing pancreatitis: nonenhancing areas of pancreatic parenchyma
Acute necrotic collections: ill-defined, heterogeneous appearance with varying densities
Walled-off necrosis: an encapsulated collection of necrotic material, usually occurring > 4 weeks after the onset of necrotizing pancreatitis
Infection: air within the pancreatic or peripancreatic tissue or fluid collections
List indications and findings of x-ray chest and abdomen.
Indications: not routinely indicated; may be performed as part of the initial workup of undifferentiated abdominal pain
On abdominal x-ray
Sentinel loop sign: dilatation of a loop of small intestine in the left upper abdomen (duodenum or jejunum)
Colon cut off sign: gaseous distention of the ascending and transverse colon that abruptly terminates at the splenic flexure.
Calcified gallstones or pancreatic stones
On chest x-ray: pleural effusion, pulmonary edema suggesting ARDS
List indications and findings of MRI abdomen.
Indications
In combination with MRCP in cases of suspected choledocholithiasis
An alternative to CT
Enlarged, edematous pancreas
Pancreatic necrosis
Complications (e.g., walled-off necrosis, pseudocysts)
List indications and findings of MRCP.
Indications: prior to therapeutic ERCP in suspected biliary pancreatitis
Evidence of choledocholithiasis
Can also identify pancreatic ductal anomalies that may trigger acute pancreatitis
List indications of ERCP.
Suspected choledocholithiasis (if MRCP or MRI are not feasible) [8]
To evaluate for sphincter of Oddi dysfunction in patients with recurrent pancreatitis and normal or inconclusive EUS and MRCP [30]
List indications and findings of endoscopic ultrasound.
Indication: evaluation of the underlying cause if routine initial workup fails to establish the etiology
Findings: occult microlithiasis, pancreatic neoplasms, chronic pancreatitis, other pancreatic parenchymal, ductal, and ampullary disorders may be identified
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