Date: May 8, 2024 • Issue no: #089
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🥤 Patience with the Pancreas
✅ Review the common diagnostic guidelines 📚 Key pearls for important patient questions 🧵 And more! |
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Patience with the Pancreas |
A 55-year-old male presents to the emergency department with severe epigastric pain radiating to his back, accompanied by nausea and vomiting. On examination, he appears uncomfortable and is tender to palpation in the epigastric region. Laboratory studies reveal elevated serum amylase and lipase levels. Imaging confirms your suspected diagnosis. Given the severity of his symptoms and the need for management, which of the following interventions should be initiated promptly? [A] Intravenous fluid resuscitation with Normal Saline [B] Intravenous fluid resuscitation with Lactated Ringer’s [C] Oral antibiotics [D] Surgical exploration
Scroll down to find the answer at the end! 👇
Need to refresh your memory before answering this question? Head over to Pathway to review the latest guidelines on Acute Pancreatitis, as well as some landmark trials.
The following summarized guidelines for the evaluation and management of Acute Pancreatitis are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2024), the American Diabetes Association (ADA 2024), and the United European Gastroenterology (UEG/ESPEN 2023), among others. |
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Answer - B. Intravenous fluid resuscitation with Lactated Ringer’s
Explanation - This patient’s presentation is consistent with acute pancreatitis, characterized by inflammation of the pancreas, often resulting from gallstones or excessive alcohol consumption. This inflammation can lead to significant fluid shifts and dehydration due to factors such as vomiting and third-spacing of fluids.
Initiating intravenous fluid resuscitation promptly is crucial in the management of acute pancreatitis to maintain perfusion, prevent dehydration, reduce pancreatic inflammation, and support renal function. The ACG 2024 guidelines recommend considering using LR over NS for fluid resuscitation, which may help decrease the risk of electrolyte abnormalities or renal injury. Other interventions, such as pain management, nutritional support, and addressing underlying causes, are also important but may not require immediate initiation in all cases
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While fluid resuscitation is important in managing acute pancreatitis, some recent studies have investigated the volume needed for adequate treatment. The WATERFALL trial (2022) assessed aggressive versus moderate fluid resuscitation. The aggressive strategy led to significantly higher fluid overload (20.5%) when compared to the moderate strategy (6.3%), with no marked improvement in clinical outcomes.
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What are the guideline recommendations for diagnosis of acute pancreatitis? - Diagnose acute pancreatitis in the presence of ≥ 2 of the following 3 criteria:
- abdominal pain consistent with the disease
- serum amylase and/or lipase > 3 times the ULN
- characteristic findings on abdominal imaging. (E)
- Consider using CRP level ≥ 150 mg/L on the third day as a prognostic factor for severe acute pancreatitis. (B)
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Consider obtaining a transabdominal ultrasound in patients with acute pancreatitis to evaluate for biliary pancreatitis and a repeat ultrasound if the initial assessment is inconclusive. (C)
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Recognize that urea > 20 mg/dL represents an independent predictor of mortality. (B)
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Recognize that procalcitonin is the most sensitive laboratory test for detection of pancreatic infection, and low serum values are strong negative predictors of infected pancreatic necrosis. (B)
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Avoid obtaining early/at-admission routine CT to determine the severity of acute pancreatitis; reserve it for patients with an unclear diagnosis or failing to improve clinically within the first 48-72 hours after hospital admission. (E)
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Obtain serum triglycerides in patients without gallstones and/or significant history of alcohol use. Suspect that hypertriglyceridemia is the cause of pancreatitis if triglyceride levels are > 1,000 mg/dL. (E)
What are the guideline recommendations for medical management of acute pancreatitis? -
Consider initiating medical therapy over early (within the first 72 hours) ERCP in patients with acute biliary pancreatitis without cholangitis. (C)
- Monitor patients with mild disease for the development of severe disease and organ failure during the initial 48 hours following admission. (E)
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Consider initiating moderately aggressive fluid resuscitation in patients with acute pancreatitis. Administer additional boluses if there is evidence of hypovolemia. (C)
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Recognize that fluid resuscitation in patients with acute pancreatitis is likely more important early in the course of the disease (within the first 24 hours). (E)
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Consider using lactated Ringer's solution over normal saline for IV resuscitation in acute pancreatitis. (C)
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Reassess fluid volumes at frequent intervals within 6 hours of presentation and for the next 24-48 hours with a goal to decrease the BUN. (E)
- Avoid administering prophylactic antibiotics in patients with severe acute pancreatitis. (D)
- Consider initiating early oral feeding (within 24-48 hours) as tolerated by the patient over the traditional NPO approach in patients with mild acute pancreatitis. (C)
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Consider using a low-fat solid diet over a stepwise liquid-to-solid approach for initial oral feeding in patients with mild acute pancreatitis. (C)
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Administer rectal indomethacin to prevent post-ERCP pancreatitis in patients at high risk of post-ERCP pancreatitis. (B)
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Obtain screening for diabetes within 3-6 months following an episode of acute pancreatitis and annually thereafter. (E)
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Acknowledgements: - Editorial Team: Jeremy Swisher, MD, Cole Phillips, MD, Khudhur Moh, MD, Hovhannes K, MD
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