A brief synopsis of AFPs "Acute Pancreatitis: Diagnosis, Prognosis, and Treatment"

A brief synopsis of 
Acute Pancreatitis: Diagnosis, Prognosis, and Treatment
JENNIFER K. CARROLL, MD, MPH, University of Rochester School of Medicine, Rochester, New York, BRIAN HERRICK, MD, University of California at San Francisco, San Francisco, California TERESA GIPSON, MD, and SUZANNE P. LEE, MD, University of Rochester School of Medicine, Rochester, New York
Am Fam Physician. 2007 May 15;75(10):1513-1520. 
http://www.aafp.org/afp/2007/0515/p1513.pdf

     Acute pancreatitis is basically an inflammation of the pancreas. The outcomes can vary widely, from a brief hospital stay to a trip to the ICU. Common risk factors include gallbladder disease or chronic alcohol use, but other risk factors including hypercalcemia, infection, drug side effects, or hyperparathyroidism could be the culprit.  If you remember the mnemonic "GET SMASHED",  it stands for gallstones, ethanol, trauma, steroids, mumps, autoimmune, scorpion stings, hyperlipidemia/ hypercalcemia/ hypothermia, ERCP, and drugs [1].  The patient will have symptoms of abdominal pain, nausea and vomiting. He or she may seem restless and present in a hunched over position.  More serious findings may be fever, hypotension,  guarding, tenderness, and respiratory distress.
     Common labs that are ordered include amylase, lipase, CBC, BMP, triglycerides, UA and an ABG. Lipase is more specific and sensitive than amylase, especially during board exams (ha ha). Newer labs, including trypsinogen activation peptide,  procalcitonin, phospholipase A2, IL-6, IL-8 and CRP have been investigated, but have limited usage so far. CRP, however, is commonly used in England. A level greater than 210 mg/L after the first four days, (or greater than 210 mg/L at the end of the first week) is evidence of a severe attack [2].
     There are many scales, criteria, and scoring systems to assess severity of pancreatitis. This article says that the CT severity index is better than the APACHE II, Imrie and Ransons. The APACHE II scale is done with an online calculator. The CT severity index is done by giving a point value according to what the CT looks like as well as the amount of necrosis seen. There are two mnemonics for ransons criteria. The first one is "GA LAW" which is used during admission. It stands for:
Glucose > 200 mg/dl
Age > 55 years
LDH > 350 U/l
AST > 250 U/l
WBC> 16,000/ul
After 48 hours the mnemonic is "C HOBBS", which stands for:
Ca < 8mg/dl
Hematocrit drop greater than 10%
Oxygen saturation less than 60 mmHg
BUN increase greater than 8 mg/dl
Base deficit grater than 4 meq/L
Sequestration of fluid greater than 600 ml
A ransons score of 0-2 indicates minimal mortality. A score of 3-5 indicates a 10-20% mortality. If the score is greater than 5, there is over a 50% mortality and may be associated with more systemic complications.  A score above 3 is considered severe pancreatitis.
     Imaging is very helpful in the diagnosis of pancreatitis. CT with contrast should be used for patients with mild, uncomplicated illness when the patient appear to be getting worse during the treatment. It is also needed for the Ct severity index. It is good if you are looking for necrosis, abscess  psuedocyst, or fluid collection. ERCP is helpful to see the pancreatic duct and should be done emergently in cases of biliary sepsis, obstruction, cholangitis, elevated bilirubin, worsening jaundice, or worsening pain.  It is also helpfull in evaluating less common causes, including sphincter of oddi problems  pancreatic divisum and duct strictures. MCRP can asses the degree of pancreatic damage, find pancreatic cysts, and find gallstones (larger than 4mm). It is also used when an ERCP is not possible. 
     As far as treatment is concerned, aggressive volume repletion and pain management are key.  It was often considered standard practice to keep the patient NPO. This article advises that total enteral nutrition has shown clear benefits in severe cases of pancreatitis. It will prevent morbidity and mortality, as well as reducing infectious necrosis. The best route has not yet been determined  Antibiotic prophylaxis has shown mixed results in recent studies. Surgery may be an option after two weeks. 


1. http://www.mnemonic-devices.info/blog/example-real-world-mnemonics/get-smashed-medical-mnemonic-for-pancreatitis/

2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503457/?page=1