- Suspect acute pancreatitis in any patient with epigastric pain and in patients with impaired general condition of unknown aetiology and a history of alcohol consumption.
- Identify acute pancreatitis at an early stage on the basis of the clinical presentation and determination of plasma or urine pancreatic amylase or trypsinogen-2-status (dipstick test).
- Refer to central hospital all patients with acute pancreatitis who have
- impaired general condition or other evidence of severe pancreatitis, or
- clearly elevated plasma CRP concentration.
History and physical examination
- Ask about alcohol consumption, biliary diseases and earlier episodes of pancreatitis.
- Girdle-like epigastric pain radiating to the back is typical, starting after the cessation of alcohol consumption.
- The general condition is most important.
- Shock, respiratory distress, anuria and mental confusion may indicate severe pancreatitis.
- Record epigastric tenderness and palpable masses.
- Examine the skin of the flanks and navel for haematomas (Grey-Turner's or Cullen's sign).
- Observe symptoms and clinical findings of peritonitis or intestinal paralysis.
- Determination of pancreatic plasma amylase and urinary amylase concentrations is suitable for basic diagnostics.
- Urine amylase above 2,000 U/l (pancreatic plasma amylase P-Amyl-P > 65 U/l; serum amylase > 300 IU/l) suggests pancreatitis, and a concentration above 6,000 U/l (P-Amyl-P > 200 U/l, serum amylase > 900 IU/l, > 3 × the upper limit of reference value) is considered diagnostic. Amylase concentrations do not correlate with the severity of pancreatitis.
- Serum lipase measurement may also be used in the diagnosis of acute pancreatitis. It’s diagnostic value is similar to amylase but the level remains increased for a longer time (3–7 days).
- Determination of serum trypsinogen may be used in diagnostics if the symptoms have lasted for a longer time. The concentration may remain increased for up to several weeks.
- Rapid urinary trypsinogen test is a suitable aid in diagnostics. A negative test result reliably rules out pancreatitis.
- Plasma CRP is a good test in the assessment of the severity of pancreatitis, although the concentration is not necessarily increased in the very initial stage of the disease. A concentration above 100 mg/l suggests severe pancreatitis.
- Marked elevations (3 ×) of ALT or AST suggest gallstone pancreatitis [Evidence Level: C]
- If the aetiology is unclear it is advisable to determine plasma calcium and fasting plasma triglyceride concentrations in the initial stage of the disease already.
- Ultrasonography is a useful preliminary method but its usefulness is decreased by intestinal air that prevents reliable visualization of the pancreas. Furthermore, ultrasonography is not suitable for the assessment of severity. Ultrasonography and magnetic resonance cholangiopancreatography (MRCP) may give clues about gallstones as the possible aetiology of the pancreatitis.
- Contrast-enhanced computed tomography is the most accurate imaging method for diagnosing and assessing the severity of pancreatitis. Before administering the contrast medium, the patient’s renal function should be checked.
Treatment of mild pancreatitis
- Even mild pancreatitis should be followed up in a hospital because of the risk of complications.
- Sufficient early fluid resuscitation is the basis of conservative treatment. Even mild pancreatitis causes dehydration, and the minimum requirement for fluids during the first 24 hours is 3–4 l. Fluid resuscitation is continued according to the clinical condition and urine output. Ringer’s solution is well suited for intravenous fluid therapy.
- Adequate analgesia and follow-up are an essential part of the treatment.
- Antimicrobial drugs, other medications and nasogastric suction have not been proven to have an impact on the healing of the disease. A nasogastric tube can be used if the patient vomits profusely because of intestinal paralysis.
- Plasma CRP and glucose, basic blood count with platelets, plasma calcium, sodium, and potassium should be determined daily.
- Sufficient rehydration is ensured by intravenous infusions with concurrent monitoring of diuresis, and peroral nutrition is started as soon as possible [Evidence Level: B].
- Urgent (during the first day) sphincterotomy and removal of gallstones from the common bile duct on ERCP improves the prognosis in severe pancreatitis, if there are signs of biliary obstruction or cholangitis [Evidence Level: B].
- In mild biliary pancreatitis, operative removal of the gall bladder during the same episode of care is aimed for.
- The treatment of necrotizing pancreatitis should be concentrated to units of specialized care with the best experience and intensive care readiness because of the risk of complications and significant mortality.
- The symptoms of severe pancreatitis, due to organ damages, include peritonitis shock, respiratory distress, anuria, and mental confusion.
- A high plasma CRP concentration (above 100 mg/l) is, along with the clinical condition, multiple organ failure or -damage and information provided by contrast enhanced computed tomography, the most accurate indicator of severe pancreatitis.
- The treatment of necrotizing pancreatitis has been changed in favour of conservative approach including aggressive fluid resuscitation (in the initial stage up to 4–6 l/day) and conservative measures maintaining cardiovascular and respiratory function (in intensive care). However, surgery may still be indicated. The primary indication for surgery is the infection of pancreatic necrosis. In the modern “step-up approach”, the treatment methods progress from radiological drainage procedures to, according to need, mini-invasive or open surgery.
- As a complication of severe pancreatitis, the intra-abdominal pressure may increase impairing respiratory function and diuresis. According to recent experience in the treatment of this so called abdominal compartment syndrome, when the intra-abdominal pressure is elevated to 25–35 mmHg, it is beneficial to perform laparotomy and leave the abdominal cavity unsutured to start the so-called "open abdomen" treatment.
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