Acute pancreatitis (AP) has increased in the past decade and accounts for over 275,000 annual hospital admissions in the U.S. and estimated medical costs of $2.5 billion. Noteworthy points are as follows:
- Morbid obesity and DM 2 are independent risk factors for AP.
- Patients with vague symptoms and minimal amylase/lipase elevation (<3 times the upper limit of normal) should not receive a diagnosis of AP.
- The most useful predictors of severe disease are elevations at admission and during the following 24 to 48 hours of the following: HCT >44%, BUN >20 mg/dL, crt >1.8 mg/dL, or SIRS (presence of ≥2 of the following signs: temperature <36 or >38 degrees centigrade, pulse >90 beats/minute, respiratory rate >20/minute or arterial carbon dioxide <32 mmHg, and white cell count <4000 or >12,000 per mm3). Consider ICU admission for these patients.
- Aggressive IV fluid therapy (lactated Ringer’s may be superior) is most critical in the first 24 hours after symptoms begin but is not very useful after 24 hours.
- With mild AP, complete resolution of pain is unnecessary before beginning low-fat, oral solid or soft feeding.
- Whether artificial enteral feeding is needed can be predicted by day 5. Nasogastric, nasoduodenal, and nasojejunal approaches have similar results. Early nasoenteric feeding within 24 hours of admission is not superior to assessing feasibility of oral feeding at 72 hours.
- Prophylactic antibiotics are not beneficial for prevention of infected pancreatic necrosis.
- Efforts for invasive intervention of pancreatic necrosis should be delayed at least 4 weeks to allow for walling of healthy tissue from necrosis.
- Alcohol remains a strong risk factor for recurrent AP. Abstinence and smoking cessation interventions can markedly reduce recurrence risk.
- Drug-induced pancreatitis accounts for <5% of cases, and the course is typically mild.
Citation(s):
Forsmark CE et al. Acute pancreatitis. N Engl J Med 2016 Nov 17; 375:1972. (http://dx.doi.org/10.1056/NEJMra1505202)