Acute pancreatitis – 10/2/18

Thanks to Tiffany for presenting the case of a middle-aged man presenting with acute onset of epigastric abdominal pain and nausea/vomiting, found to have a normal lipase initially which jumped up to 1150 48 hours later consistent with acute pancreatitis.


Clinical Pearls

  • Gallstones and ETOH account for the majority of cases of acute pancreatitis.
  • Up to 30% of cases of acute pancreatitis are idiopathic!  This is a diagnosis of exclusion.
  • Lipase typically rises within 4-8 hours after the onset of pancreatitis and lasts for >8 days as opposed to amylase (6-12 hours, lasts for 3-5 days).  Lipase is also more sensitive and specific than amylase.
  • Common electrolyte abnormalities associated with pancreatitis are hyperglycemia and hypocalcemia.
  • BISAP, Ranson’s, and APACHE II scores are useful for prognostication
  • In a patient with history of recurrent pancreatitis presenting with acute GI bleed, think hemosuccus pancreaticus (pseudoaneurysm between the splenic artery and pancreatic duct) which requires IR or surgical intervention.

Causes of pancreatitis: GET SMASHED

  • Gallstones
  • EtOH
  • Trauma
  • Scorpion bite (and Gila monster!)
  • Mumps, Malignancy (pancreatic adenocarcinoma)
  • Autoimmune (seen in IgG4 related disease and celiac)
  • Steroids
  • Hypertriglyceridemia and Hypercalcemia (unclear mechanism)
  • ERCP
  • Drugs (sulfas, thiazides, ACEi, lasix, ARVs are most common)

If you have ruled out the above etiologies, here is a more thorough list to sift through:

  • Infections
    • Viruses: coxsackie, CMV, HIV, VZV, HBV, HSV
    • Bacteria: salmonella, legionella, mycoplasma, leptospira
    • Fungi: aspergillus
    • Parasites: toxo, crypto, ascaris
  • Hypotension
  • Atheroembolism
  • Vasculitis (SLE or PAN)
  • Hereditary mutations
  • Cystic fibrosis

Work up for pancreatitis without identifiable cause:

  • EUS with bile sampling for microlithiasis
  • If EUS is negative or unavailable, then MRCP with secretin administration to evaluate dynamic obstruction or early chronic pancreatitis

Prognosis:

Capture

For a very thorough review of pancreatitis, please see this prior blog post.

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