ACUTE PANCREATITIS

Acute inflammation of the pancreas.

Cause

  • Excessive alcohol intake
  • Gall stones, biliary tract disease (obstructive cancer or anatomical abnormalities)
  • Infections, e.g. mumps, HIV, hepatitis A, ascaris
  • Drugs, e.g. sulphonamides, furosemide, lamivudine, analgesics, organosphosphate poisoning
  • Peptic/duodenal ulcers

Clinical features

  • Acute abdominal pain usually in the epigastrium radiating to the back
  • Pain worsened by eating or lying down and relieved by sitting up or leaning forward
  • Nausea, vomiting, abdominal distension
  • Fever, tachycardia, dehydration (may be severely ill with shock)
  • Abdomen is very tender but in the absence of peritonitis there is no rigidity/rebound tenderness

Complications

  • Pseudocysts
  • Necrotizing pancreatitis with infection
  • Peritonitis

Differential diagnosis

  • Perforated peptic ulcer, peritonitis
  • Acute cholecystitis, inflammation of the biliary tract
  • Sickle-cell anaemia crisis

Investigations

  • Blood: Serum analysis, complete blood count, random blood sugar
  • Raised pancreatic amylase and lipase > 3 times normal
  • Ultrasound: gallstones, pancreatic oedema, abdominal fluid
  • Liver function tests: raised liver enzymes

Management

Mild acute pancreatitis

(No organ failure, no local or systematic complications, no signs of peritonitis, normal serum
creatinine, normal haematocrit [not increased]

Early aggressive fluid resuscitation and acid-base balance

  • Prevent volume depletion (adequate fluids with Ringer’s Lactate). Give 5-10 ml/kg/hour or 250-
    500 ml of isotonic crystalloids in the first 12-24 hours or urine output of at least 0.5 ml/kg/hour

    • Give IV fluids to correct metabolic and electrolyte disturbances and to prevent
      hypovolaemia and hypotension
    • Monitor electrolytes
    • Goal is to decrease haematocrit and BUN in 48 hours, evaluate every 4-6 hours

Pain control

  • Opioids, paracetamol, epidural anaesthesia [avoid NSAIDs)
    • Rectal/IV paracetamol 500 mg 6-8 hourly
    • or Pethidine 25-100 mg SC or IM or 25-50 mg slow IV. Repeat prn every 4-6 hours
    • IV morphine 1-3 mg every 4 hours
    • Be aware of complications e.g. constipation, dysphagia, respiratory depression, confusion

Emesis

  • Anti-emetics as appropriate
    • Metoclopramide 10 mg IV/IM every 8 hours
  • Pass a nasogastric tube for suction when persistent vomiting or ileus occurs

Feeding and nutrition

  • No feeding by mouth until signs and symptoms of acute inflammation subside (i.e. cessation of
    abdominal tenderness and pain, return of hunger and well-being)
  • Provide energy with dextrose 50% 300-500 ml a day (add 50 ml to 500 ml Normal saline) to
    prevent muscle wasting
  • Start early oral re-feeding on demand, start within 48-72 hours as soon as the patient is able
    and can tolerate feeds
  • Start with clear liquids, then low fat semi-solid feeds then a normal diet – according to tolerance
  • Monitor daily for vital signs, fluid intake, urinary output, and GI symptoms
  • If oral feeding not possible, consider peripheral parenteral and central parenteral nutrition

Glycaemic control (hyperglycaemia is common)

  • Keep serum blood sugar between 6-9 mmol/l
  • Avoid hypoglycemia

Antibiotics

  • Avoid inappropriate use of antibiotics and other medications e.g for prophylaxis
  • In case of specific infection, e.g. biliary sepsis, pulmonary infection, or UTI, treat vigorously
    with appropriate antibiotic therapy

Other measures

  • Address the underlying cause as is appropriate
  • Stop alcohol or drugs
  • Mobilisation
  • Evaluation for gallstones by ultrasound scans
  • Manage complications e.g. acute peri-pancreatic fluid collections, acute necrosis, pseudocyst
Moderately acute pancreatitis
  • Transient organ failure (< 48 hours)
  • Local or systematic complications without persistent organ failure
Severe acute pancreatitis
  • Persistent organ failure (> 48 hours)
  • Either single or multiple organ failure

Treatment as above plus

  • Refer or consult with specialist at higher level
  • HDU/ICU ( monitoring and nursing)
  • Volume resuscitation
  • Pain management
  • Nutrition/ re-feeding
  • Glycaemic control
  • Nasogastric tube
  • Oxygen / mechanical ventilation
  • Renal replacement
  • Address the cause where possible
  • Manage complications as appropriate e.g. acute peri-pancreatic fluid collection, acute necrosis,
    pseudocyst
Note
  • Look out for diabetes mellitus as a consequence of damage to the pancreas

Prevention

  • Reduce alcohol intake – moderate consumption
  • Limit use of toxic drugs