Acute Pancreatitis - Diagnosis and Management - GrepMed Handbook Presentation: • Epigastric abdominal pain (90%, characteristically radiating to back), N/V (90%) • Other: Jaundice (obstruction), Periumbilical (Cullen) or flank (Grey-Turner) bruising in severe hemorrhagic. Etiology: • Gallstones (40-50%), EtOH (30%), Hypertriglyceridemia 10%), HyperCa2+ • Other: ERCP/surgery, Trauma, Drugs, Autoimmune, PUD (posterior), Anatomic (divisum/annular pancreas, sphincter dysfunction), Familial, Infectious, Ischemia, Cancer/Mets, Radiation, Cystic Fibrosis Diagnosis (2 of 3): 1) Characteristic presentation 2) Lipase > 3x ULN 3) Imaging findings Workup: • Labs: Lipase, Ca2+, LFTs, Triglycerides (>1000 mg/dL) • Imaging: US (biliary evaluation, gallstones), CT (early only to clarify diagnosis, can be normal early; late to assess for complications), MRCP (necrosis, biliary, stones), CTA if suspect hemorrhage Management: • IVF - Moderate fluid resuscitation in first 24h • Analgesia: Scheduled APAP, IV Opioids (can worsen ileus), consider pain-dose ketamine (ICU); consider epidural if available. • Nutrition: Early enteral improves outcomes, consider NGT if unable to tolerate within 48-72h. Can immediately start with low-fat (as safe as CLD). Avoid TPN. • Antibiotics: AVOID • Gallstones: Urgent ERCP (w/in 24h) if cholangitis, consider ERCP + cholecystectomy during hospitalization • HyperTrig: D10+insulin gtt (goal TG < 500-1000, closely monitor electrolytes), gemfibrozil 600 bid • HyperCa2+: Bisphosphonates, calcitonin • Infected Necrosis - Dx: FNA if suspected. Tx: ABx (pip-tazo, carbapenem or cefepime+flagyl) ± drainage. Check out https://emcrit.org/ibcc/pancreatiti for a definitive guide to diagnosis and management of pancreatitis (and discussion of fluid management) #Pancreatitis #Acute #Diagnosis #Management #Treatment #Gastroenterology
