Acute Pancreatitis

John Lieb II MD
Assistant Professor of Clinical
Medicine
Division of Gastroenterology
Acute Pancreatitis is the most terrible of
all the calamities that occur in connection
with the abdominal viscera.

Sir Berkeley Moynihan Ann Surg 1925

 Outline
Def
Clinical presentation/Differential
Epidemiol
Pathophys
Causes
Complications
Radiology
Scoring systems/prediction
Management: fluids, antibiotics, nutrition, ERCP
Long term consequences (CP, DM, cysts, bleeds)
 Acute Pancreatitis
Inflammation of the pancreas and associated
adjacent organs without evidence of chronic
pancreatitis
Atlanta Symposium in 1992 defined acute
pancreatitis clinically as 2 of 3 of the following
Typical pancreatic type pain
Radiographic findings of acute pancreatitis
Elevations in blood chemistries (typically amylase
and/or lipase >3x ULN)
 Causes of elevated:
Amylase Lipase
Renal insuf DU, renal insuff
Salivary inflammation
Small Intestinal ischemia/obstr
Ie vomitting, parotiditis
Macroamylasemia Tuboovarian abscess
Hereditary or from hetta starch Macrolipasemia (nonhodg, cirrh)
Intestinal infarct/peritonitis Tylenol OD
Through transperit absorpt
Choleitis, Salpingitis, ectopic preg
Hypotension/sepsis/DKA
Ovarian cysts, lung inflamm HIV, panc CA
Acidosis, ESLD Gullos syndrome
Intest radiation, obstruction

Cholecystitis
Colon, ovar, panc, brst, prst, lung, esoph CA
MM, pheo, appendicitis, gastroenteritis False negative amylase/lipase: Hypertrigs,
Burns, normal pregnancy, FHF stoic person (vets) who presents late
Working up false pos amylase/lipase
If obvious other cause (vomitting, tub-ov abscess)
then no further w/u needed
Serum isoamylase (35-50% of serum amyalse usually
pancreatic)
Urinary amylase (beware of spitting in cup,
munchausen)
Serum trypsin (RIA, UF, NEJM 1984).
Barely high levels: repeat the measurement in 6-
12hr
True elevations require workup, malig, CP, etc
Acute Pancreatitis: Time course of enzyme
elevations
12

10

8
Fold Lipase
increas 6
e over
normal
4

2 Amylase

0
Amylase half 0 6 12 24 48 72 96
life 10 hrs
Hours
Hours after
after onset
onset
Acute Pancreatitis

Presenting features
Abdominal pain
Nausea / vomiting
Tachycardia
Low grade fever
Abdominal guarding
Loss of bowel sounds
Jaundice
Syncope! Rare 0 20 40 60 80 100
Painless:post op, legionaires, % patients
DM, perit dialys
 Extraintestinal manifestations
Arthritis (lipase laden fluid with leuks)
Serositis (pericarditis, pleuritis)
Panniculitis, subcutaneous fat necrosis, can
look like e nodosum (1% of all cases, 10% have
it at autopsy)
Purtschers retinopathy (rare)
Sudden blindness, post retinal artery occlusion
 Pain, Oh the pain
Worse than childbirth Worse than being shot
Starts fast within 10-20min reaches peak
Third fastest pain onset in GI after perf and SMA thromb
Does not usually undulate (not colicy)
Lasts days (if no underlying chronic damage)
Longer than biliary colic which is hours
Radiate to back in 50%
Sometimes diagnosed at autopsy (painless)
Almost always causes ER visit/admission
Capsaicin, glutamate, vanilloid, ppar-gamma
 Acute Pancreatitis: Epidem
5-35/100,000
Increasing incidence (detection?meds?iatrog?)
Increases with increasing age
Onset before 14-15 yrs unusual
unless hereditary, traumatic, anatomic anomaly
250,000 admissions per year in U.S. (2nd GI)
$2 billion in direct costs per year
6th costliest GI disease behind ESLD, cancers, IBD
NIDDK funding is 11 out of 17 GI illnesses
Acute Pancreatitis Pathophysiology
Since starch and triglycerides are not stored in
the pancreas, trypsin is the major catalyst for
pancreatic autodigestion, not amylase or
lipase (but later lipase gets to abd fat.)
PREMATURE/INTRACELLULAR activation of
trypsin.
Leads to activation of chymotrypsinogen,
more trypsinogen, elastase, phospholipase A2,
complement, kinins ->>AUTODIGESTION!!
 Etiologies of Acute Pancreatitis
Biliary (gallstones) *** Ischemia/embolic***
Alcohol**** Infection (except mumps **)
Triglycerides*** Hypercalcemia (hypPTH)
pERCP,* post surgical Autoimmune/Sprue
Drugs Hereditary
(except byetta and L- Controversial (divisum/SOD)
asparagenase and trigs **) Scorpions ***
Tumors/obstruction Chemical: insecticide/MeOH
Trauma** Idiopathic: 30%!!

Number of *s denotes tendency to be severe

 Biliary anatomy
Right lobe Left lobe
Stomach
of Liver

GB

CBD

PD

Pancreas

Jejunum
Major papilla Duodenum
 Biliary
Gallstones or sludge, Microcrystals?
Most common etiology in world. Still 35% in US.
More in women
Usually small ones that dont obstruct cystic duct or
most of CBD until right at major pap
Usually pass on own, but dont be complacent!
Can be Necrotizing!!
Biliary duct dil/LFT can occur late! (insensitive!)
If fever, bili over 2, SIRS, (ie cholangitis) call adv endo
immediately.
ALT 3X ULN (>150) 50% sens and 90% specif.
First ALT then bili then ductal dilation.
ALT/AST can be 1000!
NOTE MUST BE ON CHART FROM SURGERY BEFORE D/C !
 Biliary: who has extant CBD stone?
Cholangitiscall even at 2am if look unwell, septic
TBili over 3, esp if over 5
LFT not improve, esp if pt still has pain
Pt looks unwell
High (ERCP), moderate (MRCP), low risk (watch)
Very personalized decision. Depends on local MRCP quality,
surgical expertice in intraop cholangiogram, etc
Call even on weekend
MRCP can have false pos>>>false neg
 Biliary pancitis Scenarios
PT with fever, tbili 1.8, ALT 500, AP 250, tachy, WBC
20 with 20% bands, duct dil on US, looks unwell
PT looks well but ALT still 100, AP 200 TB normal
sat nite at VA
PT was very ill when they called you, fever, tachy,
tachypnic, bili 3, AP 250, ALT 500, duct dil, but when
you arrive suddenly pt feels great, looks better, stat
labs bili now 6, AP300, ALT 640, WBC still 15 with
left shift
 Biliary pancitis scenarios
Pt with pain of 6 hours duration now, bili 4.4,
WBC 15, ALT 340, AP 300, t 100F, CT with mild AP
and ductal dil
No radiologist in house Sat 9pm at the VA
You look at CT and inform the rad PGY2 at HUP
that there is a CBD filling defect, likely stone,
about 6mm in size. He agrees he must have
missed it.
Pt still not feeling well, writhing in pain
 Biliary pancitis scenarios
Pt with fever, WBC 11, bili 2.2, ALT 300, AP 300,
AP, ER RUQ US shows gallstones, acute chole with
duct dil 2am, pt does not look bad, feeling better
than when first arrived, but still signif RUQ pain
2am surg PGY 2 says, consult GI for urgent ERCP
for cholangitis, discussed with surgery attdg and
that quote is on the chart.
ER calls you at 230am.
 Alcohol
TAKE A CAREFUL HISTORY
Often after pt stops drinking (CCK is upregul and pts
start to eat more fat/protein).
The night of the day after a binge
Typically a lot: >50g/day for years
But no amount of ETOH is safe
More in men; lipase 2X amylase?
1st or 2nd most common in US (31-40%)
Mitochondrial toxin, lysosome instability
Reactive oxygen species, proinflamm
Increased lysosome and enzyme production
Decrease panc blood flow, precipitate panc proteins
Why only 10% of alcoholics get panctis? SPINK?
Often have CP
 Triglycerides
Usually >1000: an endocrine emergency!
Can occur in 500 range
In Children it is known that keeping trigs<200
prevents AP
Alcohol raises trigs usually to 400-500 range, can
be higher
Can have normal amylase and lipase.
What about post prandial trigs?
Uncontrolled hyperglycemia can lead to high trigs
Often have CP
IV insulin works faster/better than SQ
 Trauma
Disrupt PD as pancreas crosses spine in mid
body
ERCP needed once stabilized to bridge duct
disruption with stent to prevent apoptosis of
tail.
 pERCP
Often mild/interstitial
5% of all ERCP
But only 1/1000 of those are necrotizing
pH of contrast dye? Osmolarity of contrast? Stent fell out?
Mechanical swelling of papilla? Wire in duct?
Bacterial reflux? Thermal effect of sphincterotomy?
RFs: Pt, procedure (SOD, nondil ducts, no cancer, no stones,
more cannul attempts, more panc dye injection (body, tail,
acinarizat), pt with nml panc, pdivisum/ampullectomy,
spincterotomy esp precut, dilating biliary orifice without
sphincterotomy, <50 cases/year, <200 lifetime cases)
Prophy: indocin PR? PD stents, wire guided cannulation
 Other endoscopic causes
Diagnostic or therapeutic EUS
Deep enteroscopy
Duodenal adenoma resection even if lateral
wall
 Post surgical
25% post CABG have high amylase
1% of CABG have necrotizing pancreatitis
Mechanical stretchKocher maneuver?
Ischemia?
Anesthetics (propofol/trigs)?
Cardioplegia? (CaCl during CABG)
Note: amylase/lipase elevations in ICUs are
common, most often not clinical pancreatitis
 Obstructive/Tumor
Adenocarcinoma of pancreas/Acinar cell Ca
P divisum? SOD? Long Common channel, Caroli
IPMN, neuroendocrine, mets, lymphoma
Ascariasis
Ampullary tumors/diverticula (latter, controver.)
Post acute pancreatitis with panc duct stricture
Sprue or Crohns of duodenum
ALL UNEXPLAINED PANCREATITIS PTS OVER AGE 50
OR EARLIER IF FHx OF RELEVANT CAs (RCC, Breast
CA, brain CA, uterine, etc) SHOULD HAVE A CT 6
week or so after the AP.
IPMN
Pdivisum from IU.
 Drugs
AIDS didanosine, pentamidine
Antimicrobial metronidazole, sulfonamides,
tetracycline , INH, dapsone, nitrofurantoin
Diuretics furosemide, thiazides (sulfa?)
Immunosuppressive/antimetabolite L-asparaginase,
azathioprine , 6MP, INF?, sorafinib*
Neuropsychiatric valproic acid
Antiinflammatory sulindac, sulfasalazine, 5-ASA,
salicylates
Others calcium, estrogen, tamoxifen, Byetta, TPN,
propofol, accutane, vit A
*sorafinib can raise lipase/amylase without pitis
 Drug Induced AP by timing
Early
Within 30 days
Reflects hypersenitivity or direct damage
Rash, eosinophilia
Azathiaprine/6MP, Sulfa, flagyl, ACE, salicylates
Late
Often after several months
IgG or T cell related?
Buildup of toxic metabolites?
Didanosine, pentamidine, valproic acid
 Drug induced AP by mechanism
HYPERTRIGLYCERIDEMIA
Tamoxifin, estrogen, finasteride, beta blockers, vit A,
thiazides
ANGIOEDEMA
ACE-IsBradykinin?
DIRECT TOXIC
Sulfa, diuretics
IMMUNOLOGIC
Sulfa, 6MP/Imuran
 Infectious
Viruses Mumps, coxsackievirus, hepatitis B,
cytomegalovirus, varicella-zoster, herpes
simplex, HIV, atypical dengue
Bacteria Mycoplasma, Legionella,
Leptospira, Salmonella, MAI/TB
Fungi Aspergillus, cryptococcus
Parasites Toxoplasma, Cryptosporidium,
Ascaris, Pneumocystis carinii, leshmaniasis
 Exotics
Scorpions (Trinidad/Mexico/India/Israeli)
Brown Recluse
(Sorry Santhi V, I cannot corroborate, maybe dapsone?)
Snakes (very rare)
African killer bees (very rare)
Gila Monster
 Hereditary
PRSS1
Auto dom. Incomplete pen. First attack by teens
Calcif CP is inevitable. No Tx. 20% lifetime CA risk
Islet cell autotransplant?
SPINK recessive. Not a cause, but a modifier
CFTRatypical CF panc sufficient CF
Explains many idiopathic cases. Recess.
2 CFs with two SPINKS: marked increase risk
Chymotrypsin C (rare)
Interstitial/edematous pancreatitis
Necrotizing Pancreatitis
 Mortality
Overall 2-5% and decreasing slightly

Interstitial/mild pancreatitis (80% of all cases)

1% mortality

Necrotizing/severe pancreatitis (20% of all cases)

20% mortality, long ICU stays (1-3 months)

Infected necrotizing pancreatitis (occurs late)

50% mortality
Interstitial pancreatitis
Interstitial pancreatitis
Necrosis
Necrosis
Pancreatic abscess/infected necrosis
How pts die with AP?Two Peaks
Early within 1-2 weeks and often within 72 hours:
multisystem organ failure (kidneys, lungs with
ARDS) (cant be ventillated/oxygenated even on
vent), DIC, hypocalcemia, shock/hypotension, abd
compartment synd, aspiration, cholangitis,
acidosis, hemorrhagic pancreatitis, intest ischemia
(clot in SV->SMV))
Late: pancreatic abscess/infected necrosis, usually
by 2 weeks, secondary biliary obstruction,
hypoalbuminemia, Hospital acquired (VRE, MRSA,
line infect, aspirations), PE, gastric variceal
bleeding, gut failure, neg nitrogen balance.
Hemosuccus
Pancreaticus
 Clues to send to ICU
Tachypnea Mental status changes
Oliguria <50ml/hr Uncontrol hyperglyc/hypo
Hypotension/orthostasis Cardiac ectopy (recurrent
Tachycardia >130 runs of NSVT/PVCs)
Tense, distended abd QTc>440msec
Grey-Turners/Cullens Obesity BMI>30, apple
Pallor, cold extremities Baseline dec card/pulm fn
Jaundice esp if febrile Diastolic dysf

Azotemia, hypoalbumin Hemoconcentration

Age> 55, high fluid reqm WBC>15, bands/myelos
First attack Pleural effusion
 Clinical indices of severity
RANSON
APACHE
ATLANTA
BISAP
Glasgow
Delta HCT and/or Delta BUN
 Ranson
At presentation At 48 hours
Age >55 Hematocrit Fall by 10%
White blood cell count >16 BUN Increase by 5 mg/dL
Blood glucose >200 mg/dL despite fluids
LDH >350 U/L Serum calcium <8 mg/dL
AST >250 U/L pO2 <60 mmHg
Base deficit >4 MEq/L
Fluid sequestation >6 L

1-2 criteria - > <1% mortal

3-5 cirteria - > 15% mortal
6-8 criteria- > 60% mortal
9-11 -> >75% mortal
 APACHE II
Temp high or low WBC high or low
MAP high or low Glasgow coma (low)
HR high or low pH or HCo3
(HR 60 gets 2pts!) High or low
Na high or low PaO2
K high or low Nonsurgical and
Creat elev emergency surgery
More points
Age over 44
APACHE-O
BMI>25 1 pt
BMI>30 2pts
Score <8 Mortal <4%
Score >8 8-18%
 ATLANTA (1992)
Mild vs severe (necrosis or organ failure)
APACHE8 or RANSON3
Organ failure
Systolic blood pressure <90 mmHg
Pulmonary insufficiency PaO2 60 mmHg
Renal failure Creatinine 2 mg/dl after rehydration
Gastrointestinal bleeding 500 ml in 24 h
DIC: Platelets 100 fibrinogen <10 g/l and fibrin-split
products >80 g/l
Calcium 75 mg/dl
 ATLANTA REVISED (2008)
Early severity->organs fail
Late severity->Structural (necrosis), esp infect
PERSISTANT ORGAN FAILURE (>48 hrs)
NEW DEFs of Radiographic/structural features
of severity
 ATLANTA
1992 Revised, 2008

Interstitial vs necrotic Interstitial edematous panc

Sterile necrosis
Infected necrosis

Pseudocyst vs abscess Acute

Necrosis vs fluid, sterile vs infected
Chronic
Pseudocyst vs walled off necrosis
Sterile vs infected
 BISAP
SIRS
T >38.5C or <35.0C, HR>90,
RR >20 or PaCO2 <32 mm Hg
WBC >12,000, <4000 or >10 percent immature (band)
forms
BUN>25
Age>60 0-2 pts: <2% mortal
3-5pts: 22% mortal
Pleural effusion
Altered mental status (glasgow CS < 15)
 Glasgow
Age >55
WBC >15
At admission and at 48hr
LDH>600 Score 0 to 2: 2% mortality
Glucose >180 Score 3 to 4: 15% mortality
Score 5 to 6: 40% mortality
Album <3.2 Score 7 to 8: 100% mortality
Calcium <8
PaO2<60
BUN>45
Grading based upon findings on unenhanced CT BALTHAZAR SCORING

Grade Findings Score

Normal pancreas - normal size, sharply defined, smooth contour,
A homogeneous enhancement, retroperitoneal peripancreatic fat 0
without enhancement
Focal or diffuse enlargement of the pancreas, contour may show
B irregularity, enhancement may be inhomogeneous but there is no 1
peripancreatic inflammation
C Peripancreatic inflammation with intrinsic pancreatic abnormalities 2

D Intrapancreatic or extrapancreatic fluid collections 3

Two or more large collections of gas in the pancreas or
E 4
retroperitoneum
Necrosis score based upon contrast enhanced CT
Necrosis, percent Score
0 0
<33 2
33-50 4
50 6
 Liebs Orderset
Call for temp>100.5 or <97, HR>100 or <50, U/O <10cc/kg/hr, MAP<60,
RR>12
FS q4hr. Call if >200 or <60
I/O check q4hr
Dilaudid PCA, zofran/phenergan for N
IV H2 blocker if not already on something. Good for first few dys, after
that probably would not use esp if not on it on presentat.
Hold ACEI
NPO except comfort swab
If neighbor not NPO, get private room.
Repeat BMP/CBC in 4-6hrs after last one, consider LFT, mag, phos,
cal/album repeat then too.
 Fluids: Theory and Data
Principles/theory:
Fluid prevents capillary microthrombi (necrosis?). Improves renal perfusion
Can we prevent necrosis? First 12 hours maybe the key
Once necrosis occurs, be careful with over resuscitation
Often these pts have low albumins and have near abd compartment
anyway
Bolus, frequently. A pulse jet, not a hose! Think sepsis goal directed
therapy
Data: retrospective more fluids are bad, classic causality bias
Goal directed no better: classic referral bias (post hoc, LR better)
China RCT: Colloid like heta starch (HESPAN)better? Really?
But Large studies in all takers with shock show increased ARF, coagulopathy and death with heta starch
 Fluids, practical
MD Stay in house until pt makes urine.
Have night person in house check U/O, glucoses and f/u repeat
BUN/creat/CBC
Send to ICU NOW! if hemoconcentration, question of abd
compartment, elev BUN, oliguria
LR for first 1-2 Ls unless hypercal/kal. If no U/O may have to switch
to NS AND BOLUS another 1-2L. Once second lytes back and OK and
if urinating can do LR again
Typically 250cc/hr or more for first 12 hr.
Care with old age >75, diastolic dysf, CRI, baseline
edema/hypoalbum, known necrosis (ie late presentation)
When in doubt give more fluids, consider CVP monitoring
 Imaging now or later?
RUQ US STAT anyone with no ETOH Hx and
with intact GB and with elv transaminases/bili.
CT: only those with questionable dx or maybe
very ill about to be intubated or whisked to OR
or >72 hrs into course.
Is it a perf DU? But a KUB will help
No CT post ERCP.
MRCP can be done without gad!
Future: 13NH3 PET
 Nutrition in acute pancreatitisideal
world
Goals: rest the pancreas/avoid bile flow
Post Lig o Treitz, small volumes
Can use elemental/MCTs (medium chain trigs)
Avoid aspiration
Give with enzymes
RCT comparing stomach feeds to TPN found
stomach feeds superior if started within 48hr.
RCT comparing post LOT feeds superior to TPN.
Try to avoid TPN-- cost, infection, proinflam
Dobhoff feed everyone with AP (DDW 2012)?!!
 Nutrition in acute pancreatitisreal
world
Most mild AP resolves in an few days, dont need
nutrition suppl.
Most necrotizing panc have partial duodenal sweep
obstruction so tough to pass dobhoff.
Sedation for GI guided nasojej feed tube may require
general due to aspiration risk. Long 1.5hour
procedures at least.
Most necrot panc are hypoalbum, hypoprotein.no
oncotic pressure to absorb enteral
Ileus often present in necrotizing panc.
Pts are high risk of aspiration of feeds.
MCTs, elemental feeds expensive, almost like TPN
 When to use antibiotics?
Never for prophylaxis?
If use antibiotics should be broad.
Use if cholangitis suspected (amp/sul is all that is needed if no
pancreatic necrosis)
Meropenem (MRSA, anaerobes, GNR) or pip/tazo
If PCN all, can use Vanco, levo and/or azactam, flagyl
Dont forget fungi if recent surg/intervention or if failing a
carbepenem.
Dont forget VRE.
Ecoli 51%, enterococcus 19%, staph 18%, klebs10%, proteus
10%, pseudomonas 10%, bacteriodes 6%
When should IR drain a collection?
Never?Should only tap and send for culture,
if grow a bug/bugs?
In practice, IR tends to leave a drainmaybe
bad!
Typically surgery team should be aware of pt
before you send to IR (you infect the surg
bed!)
If IR drain, should be retro approach
 Infected necrosis, new reality
NEJM april 2010, Dutch group, 88pts, RCT, PANTER
Step up approach
Open laparotomy (bilateral subcostal) vs IR (12 Fr,
multiple drains, only 2 endoscopic followed by
retroperit debride (VARD) )
No mortal diff. 10% less cost in IR approach.
Combined end point death or major comlx reduced
from 69% to 40%.
Open pts had more reoperations for sepsis
50% were not university hospitals, but were tertiary
so were surgeons not as good? Why open approach,
bilater subcostal?
More of a test of VARD vs open not IR vs open
Infected necrosis principles of mngmt
Wait as long as you can before intervening
Ideally at least 3-4 weeks
Even if that means intubation, dobhoff feeds
Let the bed mature/get walled offthis allows for
IR/Endoscopic management
New data suggest conserv mngmt for all necrosis has a
7% mortal
Surgery series, 25-50% mortal (old studies)
Newer surg series say 50% moral in first 14 dy, 15% at 30 or
more days
 Endoscopic necrosectomy
Must be within 1cm of stomach, walled off and mature
Avoid if resp unstable, OK if intubated already
If pseudoaneurism, must embolize in IR first.
Endoscopic series
0 -7.5% mortality (2/96)but these are sick pts, many too sick
for surgery
Median scopes: 5
Morbidity 25%, particularly bleeding, aspiration, abscess
80-90% successful
F/u 43 mo
Old teaching not for infected necrosisno longer!
 When to call a surgeon?
Pt unstable.
Infected necrosis proven or suspected. They may not
intervene until later, but let them know
Abdominal compartment syndrome (ck foley pres)
Pt with multiple poor prognostic signs, age, WBC, oliguria,
SIRS
ELECTIVELY WITH ANYONE WITH STRONG SUSPICION FOR
GALLSTONE ETIOLOGY WITH GB STILL IN SITU. MUST HAVE
CONSULT ON CHART AND F/U ARRANGEDHIGH
RECURRENCE RATE W/O CHOLE
Pt in ICU, cant eat/tolerate enteral, not improving
 Scenarios
Alcoholic, 3 attacks of AP from Sept to Feb with very similar
CT findings, ER visit in April for same, but no CT done. Pt
insists feels much worse sense april, early satiety, nausea
Alcoholic presents to ED in extremis with acute onset abd
pain 2 hours ago, AP, tachypnic, distended, not tense, ileus
BSs, hypotensive, creat 1.5 (was 0.8), BUN 50, was 5,
afebrileCT or no CT? what else to do? VA?
50 yo main line lawyer with unexplained AP neg US, nml
trigs I dont want a CT, too many rads. MRI, cost
ineffective
 Scenarios
50 yo poorly controlled DM, obese, with 24 hrs abd pain,
AP, after eating BarBQ/fries/cheesecake and two beers
WBC 15, glucose 400, creat 2.2, on admit up from 1.2, trigs
400 after 36 hr fast
Doing well on med floor, feels better, FS 250
CT now shows 10% necrosis and fluid collection about 3cm
Pt wants to eat and get outa here
Enthusiastic med resident calls, hey GI/IR, please Drain
collection?
 Scenarios
Alcoholic, severe presentation with SIRS, hypoxia,
oliguria, gets intubated and then few days later,
generally better. Initial CT on admit revealed
mild AP with peripancreatic fluid
Febrile on admit, deferversed after 2-3 days, now
has few temps 100F in last 48 hours. You are
called b/c ICU wonders why pt still distended, not
tolerating dobhoff feeds, not weaning. You note
initial WBC of 25, currently 15.
What do you do next?
 Scenarios
OSH doc (GI or gen surg) calls you at 2am on Sat
nite from Poconos or S Jersey (200bed hosp)
Pt with severe AP in their ICU same scenario as
last one, with CT showing 50% gland necrosis
with extensive peritoneal/retroperit necrosis, but
doc asksthis area has to be drained, Im going
to call in IR for perc drain and then we will send
pt to you, OK? Do you accept pt?
 Scenario
You are the PGY4 on call
New PGY6 starting an ERCP rotation (20th ERCP)
ERCP done for intermitt dil CBD and RUQ pain with
normal LFT, biliary sphinct done in this young female,
age 20 with no alcohol history. Never had pancreatitis.
Never had DM No stones found, no stent used,She
smokes. She is 56 and weighs 190lbs, pt admitted for
pain/AP post procedure.
Floor nurse calls you for glucose on panel is 300.
Worried? Not worried? What other questions should
you ask? How to best manage this pt
 Scenario
Same pt calls you from home, has pain, thinks it is gas
pains. What should you do?
Different pt just had a small intestine polyp removed by
Dr. Ginsberg with PGY5 at 1pm, calling you with same at
8pm. She also saw a plastic straw in her BM just now.
Is that OK doc? Ran out of her pecs last week. can you
just get me a few more pecs? I will be OK. What do you
do?
Dr. Katzkas IBS pt had a colonoscopy today and calling
you with same. You note 20 calls in EPIC in the last month
for various things. You note 3 CTs in the last 2 years in
EPIC What do you do?
 Scenario
44 yo Main line lawyer with ideopathic Acute relapsing
panc. Uncle had bad attacks of abd pain.
Thin build, jogger, no other med problems.
Calls you in ER Im waiting too long Cant you do
something?! I feel terrible. The pain is unbelievable
First attack was 9 months ago. Was in ICU with
necrosis, ARF, tachypnea, but resolved. Two more
attacks about every 3 mo since but not in ICU. Last CT
3 mo ago without necrosis or collections
Worried? Not worried? Why? What do to next?
 Take home points AP
Causes, presentation, labs (incl trigs!) CAN BE PAINLESS!!!
Causes of false pos/false neg amylase/lipase (>3X ULN!!!)
Predict the problem pt:
age, abd obesity, SIRS, WBC, BUN, glucose, first attack etc
Know the most severe etiologies, GET TRIGS EARLY/ADD ON!!!!
Triage (scoring systems)
Tiger or kitty (ie necrotic vs interstit)? Time will tell
Hydrate hydrate hydrate for early disease by boluses, LR,
consider colloid/heta starch if already necrosis
Monitor Urine output, glucoses get 6 hr post CBC/BUN
The first 12-24 hours should feel labor intensivethat means
you are doing it right!
Never hesitate to send to ICU if your gut is concerned
Know how to recognize severe AP by CT criteria
RUQ US first test of choice for unexplained
(non con CT or noncon MR when US not available or when no GB)
CT with contrast useful later (48 hrs or more) or if other diff dxs
 Take home points in AP
CT more liberally later on (cyst or not)
Know what a pseudoaneurism is and how to deal
LFT abnml (esp ALT) predict biliary source (LABS are 12-24hr
behind the pt!)
ERCP for cholangitis in biliary pancreatitis
Know when to MRCP (noncont if nec) vs ERCP
Know who gets most severe pERCP pancreatitis (needle knife,
SOD, ampullectomy, p divisum, etc) and RFs for such
Know 2 mortality peaks and the causes
Nutrition (early dobhoff jejunal feeds if necro)
Antibiotics only when infected necrosis or cholangitis/biliary
pancreatitis
Call Surgery for instability, abd compart, biliary, suspected
abscess, pt failing to fly
Do not call IR until after surgeon involved (ideally panc surg)
If call IR, encourage VARD if possible (left retroperiton)
John.Lieb@uphs.upenn.edu
215 823 5800 ext 3514