ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Clinical Case-Based Learning (Day Two) | April 2023-Acute Pancreatitis Update 2023

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This document provides an update on acute pancreatitis (AP) and its management. AP is an inflammatory disorder of the pancreas and peri-pancreatic tissues and is the number one gastrointestinal cause of hospitalization in the US. The etiologies of AP include gallstones, alcohol, iatrogenic causes, medications, trauma, autoimmune conditions, hypertriglyceridemia, pancreatic anomalies, and idiopathic causes. Medication-induced AP is rare but can be caused by medications such as azathioprine, furosemide, and estrogens, among others.<br /><br />Pancreatic anomalies discussed include pancreas divisum, hereditary pancreatitis, and autoimmune pancreatitis (AIP). Pancreas divisum is the most common congenital malformation of the pancreas and may be associated with recurrent AP. Hereditary pancreatitis is often caused by variants in the PRSS1 gene and has a significantly higher risk of developing pancreatic cancer. AIP is characterized by granulocytic lesions and can be type 1 (IgG4-positive) or type 2 (no IgG4 positivity).<br /><br />The presentation of AP includes sudden onset epigastric pain, often radiating to the back, and may be associated with nausea and vomiting. Diagnosis is typically made based on abdominal pain, elevated serum amylase or lipase levels, and characteristic findings on imaging. Evaluation includes laboratory tests such as liver function tests, triglycerides, and IgG4 levels, as well as imaging modalities like ultrasound and abdominal CT.<br /><br />Management of AP involves hospital admission, fluid resuscitation, pain management, and monitoring of vital signs and laboratory markers. Nutritional support is important, with enteral nutrition preferred when feasible. Antibiotics are generally not recommended unless specific indications are present, such as biliary sepsis or intraabdominal sepsis. ERCP may be necessary for conditions such as cholangitis or choledocholithiasis. Surgery is now mostly replaced by endoscopic fluid collection management, but may still be necessary in severe cases or for cholecystectomy in gallstone pancreatitis.<br /><br />Complications of AP include pancreatic pseudocysts, pancreatic necrosis, multi-organ failure, and various obstructions. Management of pseudocysts depends on symptoms, with observation or drainage options available. The document concludes with practice pearls emphasizing the importance of early diagnosis, goal-directed fluid therapy, and the use of scoring systems and SIRS evaluation to guide management. Additionally, appropriate use of imaging modalities and interventions, such as ERCP, should be considered based on specific indications.

Asset Subtitle

Sarah Enslin, PA-C

Keywords

acute pancreatitis

inflammatory disorder

pancreas

gallstones

alcohol

pancreatic anomalies

diagnosis

fluid resuscitation

nutritional support

complications