II. Causes

  1. See Pancreatitis Causes
  2. See Medication Causes of Pancreatitis
  3. Adult common causes
    1. Alcohol Abuse (35% of cases)
    2. Cholelithiasis (40% of cases)
  4. Children common causes
    1. Infection (e.g. Mumps, Viral Hepatitis, Coxsackievirus, Ascariasis, Mycoplasma)
    2. Abdominal Trauma (e.g. handlebar injury)

III. Symptoms

  1. Abdominal Pain
    1. Pancreatitis may be painful in some cases
    2. Mid-Epigastric Pain, Left Upper Quadrant Abdominal Pain or Periumbilical Abdominal Pain
    3. Radiation into the chest or mid-back
    4. Worse with eating and drinking (especially fatty foods) and in supine position
    5. Boring pain that starts episodically and advances to become constant
  2. Associated gastrointestinal symptoms
    1. Nausea or Vomiting
    2. Indigestion
    3. Abdominal bloating, distention or fullness
    4. Clay-colored stool
  3. Other associated symptoms
    1. Decreased urine output
    2. Hiccups
    3. Tactile warmth

IV. Signs

  1. General
    1. Low grade fever
    2. Altered Mental Status (severe cases)
  2. Cardiopulmonary Exam
    1. Tachycardia
    2. Hypotension
    3. Hypoxemia (25%)
    4. Left basilar rales (Pleural Effusion)
  3. Abdominal Exam
    1. Abdominal tenderness and guarding in the upper quadrants
    2. Peritoneal signs may be present (e.g. abdominal rigidity or Rebound Tenderness
    3. Bowel sounds decreased
    4. Palpable upper abdominal mass
    5. Cullen's Sign (periumbilical discoloration with subcutaneous Ecchymosis and edema)
    6. Grey Turner's Sign (flank discoloration with Ecchymosis)
  4. Skin Exam
    1. Erythematous skin Nodules (Subcutaneous Fat Necrosis)
    2. Jaundice (severe cases)

V. Labs

  1. Approach
    1. Consider obtaining Serum Amylase and serum Lipase simultaneously on initial evaluation
      1. Expect both increased in Pancreatitis (question diagnosis if only 1 increased)
      2. Serum Lipase to amylase ratio >4 (and especially >5) strongly suggests Alcoholic Pancreatitis
  2. Serum Lipase elevated
    1. Serum Lipase >540 U/L (3 times normal)
      1. Test Sensitivity for Pancreatitis: 96% (and LR+ 30)
      2. Test Specificity for Pancreatitis: 96% (and LR- 0.03)
    2. Returns to normal in 7-14 days
  3. Serum Amylase elevated
    1. Serum Amylase>360 U/L (3 times normal)
      1. Test Sensitivity for Pancreatitis: 95% (and LR+ 21)
      2. Test Specificity for Pancreatitis: 95% (and LR- 0.05)
    2. Returns to normal in 48-72 hours
    3. Precautions
      1. Normal amylase does not exclude Pancreatitis
      2. Level of elevation does not predict disease severity
  4. Serum Electrolytes
    1. Hypocalcemia (25%)
    2. Hyperglycemia
    3. Hypomagnesemia (Alcoholism)
    4. Hypophosphatemia (Alcoholism)
  5. Complete Blood Count (CBC)
    1. White Blood Cells increased to 15k-20k
  6. Fasting Triglycerides
    1. Hypertriglyceridemia (15%)
  7. Urinary trypsinogen-2 Level
    1. May help predict Pancreatitis severity
    2. Urinary trypsinogen-2 >50 ng/ml
      1. Test Sensitivity for Pancreatitis: 92% (and LR+ 13.1)
      2. Test Specificity for Pancreatitis: 93% (and LR- 0.09)
  8. Liver Function Tests
    1. Gallstone Pancreatitis
      1. Serum Bilirubin elevated
      2. Alkaline Phosphatase elevated
    2. Alcoholic Pancreatitis
      1. Aspartate Aminotransferase elevated (AST) increased more than Alanine Aminotransferase (ALT)
  9. Prognostic indicators
    1. Hypoalbuminemia
    2. Lactate Dehydrogenase (LDH) elevated
    3. Venous Blood Gas (or Arterial Blood Gas)
    4. Serum Calcium level
    5. C-Reactive Protein
    6. Interleukin-6 (IL-6) and interleukin-8 (IL-8) if available
    7. Urinalysis

VI. Diagnostics

  1. Electrocardiogram
    1. ST segment abnormality
    2. T Wave abnormality

VII. Imaging: First-Line Studies

  1. Right Upper Quadrant Transabdominal Ultrasound
    1. First-line study in Acute Pancreatitis evaluation (but limited by body habitus and overlying bowel gas)
    2. Used to identify Cholelithiasis
      1. Gallstone Test Sensitivity 87-98%
    3. May demonstrate Pancreas enlargement or edema
  2. CT Abdomen with contrast (preferred imaging modality)
    1. First-line study in severe Abdominal Pain, pancreatic necrosis or other complications are suspected
    2. Identifies pancreatic edema and necrosis as well as extrapancreatitc changes including fluid accumulation
    3. Test Sensitivity for severe Pancreatitis: 78% (and LR+ 5.57)
    4. Test Specificity for severe Pancreatitis: 86% (and LR- 0.26)
    5. Predicts and evaluates Pancreatitis complications, length of hospital stay and prognosis
      1. See CT Severity Index in Pancreatitis (Balthazar Computed Tomography Severity Index)

VIII. Imaging: Cholangiography

  1. Magnetic Resonance Cholangiopancreatography (MRCP)
    1. Consider in cases where ERCP not possible
    2. Similar efficacy to CT in identifying Pancreatitis
    3. Detects Common Bile Duct Stones in 81-100% of cases
      1. Negative Predictive Value: 98%
      2. Positive Predictive Value: 94%
      3. May miss Gallstones <4mm
  2. Endoscopic Ultrasonography
    1. Gallstone Test Sensitivity 100%, Specificity 91%
  3. ERCP Indications
    1. Evaluate atypical causes of Pancreatitis
      1. Microlithiasis
      2. Sphincter of Oddi Dysfunction
      3. Pancreas divisium
      4. Pancreatic duct strictures
    2. Urgent intervention
      1. Biliary Sepsis
      2. Biliary obstruction and severe Pancreatitis
      3. Ascending Cholangitis
      4. Progressive Jaundice or Hyperbilirubinemia

IX. Imaging: Other studies

  1. Abdominal XRay (non-specific abnormalities in 50%)
    1. Total or partial ileus (Sentinel loop)
    2. Spasm of transverse colon
  2. MRI Abdomen
    1. Indications
      1. IV contrast contraindicated
      2. Unclear diagnosis
      3. Refractory Acute Pancreatitis course after 2-3 days of conservative management
    2. May better defining peripancreatic changes
    3. Pancreatitis Test Sensitivity 83%, Specificity 91%
    4. Test Sensitivity for Pancreatitis: 79%, and for severe Pancreatitis, 83%
    5. Test Specificity for Pancreatitis: 92%, and for severe Pancreatitis 91%

X. Diagnosis

  1. Atlanta Criteria (requires 2 of 3 findings)
    1. Abdominal Pain suggestive of Pancreatitis
    2. Serum Amylase or serum Lipase increased >3 fold over normal level
    3. Characteristic imaging findings

XI. Differential Diagnosis

  1. Bowel perforation (peptic ulcer perforation)
  2. Acute Cholecystitis or Ascending Cholangitis
  3. Acute Intestinal Obstruction
  4. Mesenteric Ischemia
  5. Renal Colic
  6. Myocardial Ischemia (Angina)
  7. Aortic Dissection
  8. Connective Tissue disorders
  9. Pneumonia
  10. Gastric outlet obstruction
  11. Acute Hepatitis
  12. Diabetic Ketoacidosis
  13. Pancreatic Cancer
  14. tubo-ovarian abscess

XIII. Management

  1. Gastrointestinal rest
    1. Nothing by mouth
    2. Consider nasojejunal Enteral Nutrition
      1. Preferred over parenteral nutrition due to decreased infections and surgical interventions and shorter hospital stays
      2. May not be tolerated in severe ileus or very low oncotic pressure
      3. Marik (2004) BMJ 328:1407-10 [PubMed]
    3. Parenteral Antacid
      1. H2 Blocker (e.g. Ranitidine) or
      2. Proton Pump Inhibitor (e.g. Pantoprazole)
    4. Transition back to oral intake
      1. Re-initiate oral clear liquids when pain is well controlled without Opioid Analgesics (typically day 3-6)
      2. Advance to low fat full liquids and then to low fat regular diet
  2. Intravenous hydration
    1. Initial: 20 ml/kg LR or NS
      1. Lactated Ringers is preferred in Acute Pancreatitis (decreased systemic inflammation)
      2. Wu (2011) Clin Gastroenterol Hepatol 9(8):710-7 [PubMed]
    2. Next: Fluid Resuscitation up to 250 to 500 ml/hour for up to 48 hours to maintain urine output >0.5 ml/kg/h
      1. Follow IVC Ultrasound for Volume Status
      2. Follow Blood Urea Nitrogen
  3. Pain Management
    1. Opioid Analgesics
      1. Historically Meperidine (Demerol) was used (but has fallen out of favor due to associated risks)
  4. Monitoring
    1. Vital Signs and urine output recorded every 1-2 hours initially
      1. Transfer patients to intensive care for Hypotension, Hypoxemia or oliguria despite aggressive rehydration
    2. Physical examination every 4 to 8 hours
      1. Observe for Altered Mental Status
      2. Abdominal exam for marked abdominal firmness (Abdominal Compartment Syndrome, third spacing)
    3. Laboratory tests every 6 to 12 hours
      1. Comprehensive metabolic panel
      2. Complete Blood Count
      3. Serum Calcium
      4. Serum Magnesium
      5. Serum Glucose
      6. Blood Urea Nitrogen
    4. Imaging
      1. Consider repeat CT Abdomen for clinical worsening or signs of complications
  5. Electrolyte disturbance
    1. Hypocalemia (related to saponification)
      1. Replace Serum Calcium as needed
  6. Antibiotics
    1. Absolutely indicated only for concurrent infection
    2. Controversial whether to use in pancreatic necrosis
      1. Infections occur in one third of necrotizing Pancreatitis cases
      2. American Gastroenterological Association recommends antibiotics in necrosis of >30% of Pancreas
    3. Imipenem/Cilastin (Primaxin) may be preferred if antibiotics are initiated
      1. Villatoro (2010) Cochrane Database Syst Rev (5): CD002941 [PubMed]
    4. Do not use Probiotics (contraindicated in Acute Pancreatitis)
      1. Besselink (2008) Lancet 371(9613): 651-9 [PubMed]
  7. Surgical debridement indications
    1. Gallstone Pancreatitis
      1. Cholecystectomy is contraindicated in necrotizing Pancreatitis until inflammation improves
      2. Early Cholecystectomy shortens hospital stay without increased surgical complications
        1. Aboulian (2010) Ann Surg 251(4): 615-9 [PubMed]
      3. Consider ERCP with sphincterotomy
        1. Indicated in severe gallstone Pancreatitis (especially if Acute Cholangitis is present or unresolved obstruction)
        2. Sharma (1999) Am J Gastroenterol 94(11): 3211-14 [PubMed]
        3. Ayub (2004) Cochrane Database Syst Rev (4): CD003630 [PubMed]
    2. Non-Gallstone related
      1. Surgical indications
        1. Infected pancreatic necrosis
        2. Pancreatic necrosis with clinical deterioration
        3. Severe Pancreatitis and persistent fluid collections (e.g. >2 weeks after onset)
      2. Approach
        1. Minimally invasive techniques are preferred (e.g. percutaneous CT guided aspiration)

XIV. Course

  1. Restart clear liquids on day 3-6
  2. Most cases subside in 3-7 days (90%)

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Ontology: Acute pancreatitis (C0001339)

Definition (NCI) An acute inflammatory process that leads to necrosis of the pancreatic parenchyma. Signs and symptoms include severe abdominal pain, nausea, vomiting, diarrhea, fever, and shock. Causes include alcohol consumption, presence of gallstones, trauma, and drugs.
Concepts Disease or Syndrome (T047)
ICD9 577.0
ICD10 K85 , K85.9
SnomedCT 39726008, 155834006, 197457003, 266476001, 197461009, 197456007
English PANCREATITIS ACUTE, Acute pancreatitis NOS, Acute pancreatitis unspecified, Pancreatitis, acute, acute pancreatitis (diagnosis), acute pancreatitis, Pancreatitis acute, Acute pancreatitis, unspecified, Acute Pancreatitis, Acute pancreatitis unspecified (disorder), Acute pancreatitis NOS (disorder), Acute pancreatitis, AP - Acute pancreatitis, Acute pancreatitis (disorder), acute; pancreatitis, pancreatitis; acute, Acute pancreatitis (disorder) [Ambiguous]
Italian Pancreatite acuta
Dutch acute pancreatitis, acuut; pancreatitis, pancreatitis; acuut, Acute pancreatitis, pancreatitis acuut
German akute Pankreatitis, Akute Pankreatitis, PANKREATITIS AKUT, Pankreatitis akut
Japanese 急性膵炎, キュウセイスイエン
French PANCREATITE AIGUE, Pancréatite aiguë
Spanish PANCREATITIS AGUDA, inflamación aguda del páncreas, pancreatitis aguda, SAI, pancreatitis aguda, SAI (trastorno), pancreatitis aguda no especificada, pancreatitis aguda no especificada (trastorno), pancreatitis aguda (concepto no activo), pancreatitis aguda (trastorno), pancreatitis aguda, Pancreatitis aguda
Portuguese PANCRETITE AGUDA, Pancreatite aguda
Czech Akutní pankreatitida
Korean 급성 췌장염(이자염), 상세불명의 급성 췌장염
Hungarian Acut hasnyálmirigy-gyulladás, Acut pancreatitis

Ontology: Pancreatitis (C0030305)

Definition (MEDLINEPLUS)

The pancreas is a large gland behind the stomach and close to the first part of the small intestine. It secretes digestive juices into the small intestine through a tube called the pancreatic duct. The pancreas also releases the hormones insulin and glucagon into the bloodstream.

Pancreatitis is inflammation of the pancreas. It happens when digestive enzymes start digesting the pancreas itself. Pancreatitis can be acute or chronic. Either form is serious and can lead to complications.

Acute pancreatitis occurs suddenly and usually goes away in a few days with treatment. It is often caused by gallstones. Common symptoms are severe pain in the upper abdomen, nausea, and vomiting. Treatment is usually a few days in the hospital for intravenous (IV) fluids, antibiotics, and medicines to relieve pain.

Chronic pancreatitis does not heal or improve. It gets worse over time and leads to permanent damage. The most common cause is heavy alcohol use. Other causes include cystic fibrosis and other inherited disorders, high levels of calcium or fats in the blood, some medicines, and autoimmune conditions. Symptoms include nausea, vomiting, weight loss, and oily stools. Treatment may also be a few days in the hospital for intravenous (IV) fluids, medicines to relieve pain, and nutritional support. After that, you may need to start taking enzymes and eat a special diet. It is also important to not smoke or drink alcohol.

NIH: National Institute of Diabetes, Digestive and Kidney Diseases

Definition (MSHCZE) Akutní p. je náhle vzniklé, prudce a těžce probíhající onemocnění s výraznou bolestí břicha, zvracením, horečkou až vznikem šoku (náhlá příhoda břišní). Někdy vzniká v souvislosti se žlučovými kaménky, může být vyprovokována těžkou dietní chybou, alkoholem nebo některými celkovými onemocněními např. hyperparatyreózou. Těžká forma vede k hemoragické nekróze. Vyžaduje intenzivní léčbu(tlumení bolesti, somatostatin, blokátory žaludeční sekrece, infuze, umělou výživu, antibiotika, léčbu šoku atd.). Lehčí formy se někdy označují jako „podráždění“ (iritace) pankreatu. Chronická p. vznikne někdy po akutní, jindy se rozvíjí samostatně. Má různé projevy bolesti, záchvaty akutní p., poruchy trávení. Komplikací zánětů může být vznik dutiny (cysty či spíše pseudocysty), která může stlačovat některé okolní orgány a být někdy důvodem k operaci. Onemocnění slinivky vyžaduje přísnou tzv. pankreatickou dietu. Jsou zakázány přepalované tuky a tučná jídla vůbec, káva, alkohol apod. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI_NCI-GLOSS) Inflammation of the pancreas. Chronic pancreatitis may cause diabetes and problems with digestion. Pain is the primary symptom.
Definition (NCI_CTCAE) A disorder characterized by inflammation of the pancreas.
Definition (NCI) Inflammation of the pancreas.
Definition (CSP) acute or chronic inflammation of the pancreas due to autodigestion of pancreatic tissue by its own enzymes.
Definition (MSH) INFLAMMATION of the PANCREAS. Pancreatitis is classified as acute unless there are computed tomographic or endoscopic retrograde cholangiopancreatographic findings of CHRONIC PANCREATITIS (International Symposium on Acute Pancreatitis, Atlanta, 1992). The two most common forms of acute pancreatitis are ALCOHOLIC PANCREATITIS and gallstone pancreatitis.
Concepts Disease or Syndrome (T047)
MSH D010195
ICD10 K85.9
SnomedCT 393591004, 197461009, 75694006
LNC LA15860-2
English Pancreatitides, PANCREATITIS, Pancreatitis, pancreatitis (diagnosis), pancreatitis, Pancreatitis NOS, Pancreatitis [Disease/Finding], pancreas Inflammation, Already mapped above AAHA ID #: 933, Pancreas inflamed, Pancreatitis (disorder), Pancreatitis, NOS
French PANCREATITE, Pancréatite SAI, Pancréatite
Portuguese PANCREATITE, Pancreatite NE, Pancreatite
Spanish PANCREATITIS, Pancreatitis NEOM, inflamación del páncreas, pancreatitis (trastorno), pancreatitis, Pancreatitis
German PANKREATITIS, Pankreatitis NNB, Pankreatitis, Bauchspeicheldrüsenentzündung
Dutch pancreatitis NAO, pancreatitis, Pancreatitis
Italian Pancreatite NAS, Pancreatite
Japanese 膵炎, 膵炎NOS, スイエンNOS, スイエン
Swedish Bukspottkörtelinflammation
Czech pankreatitida, slinivka břišní - zánět, pankreas - zánět, Pankreatitida, Pankreatitida NOS, zánět slinivky břišní
Finnish Haimatulehdus
Russian PANKREATIT, ПАНКРЕАТИТ
Croatian PANKREATITIS
Polish Zapalenie trzustki
Hungarian Pancreatitis, Pancreatitis k.m.n.
Norwegian Bukspyttkjertelbetennelse, Pankreatitt