Education practice
Acute Pancreatitis Part I: Approach to Early Management

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Clinical Scenario

A 51-year-old man presents to his local hospital for evaluation of abdominal pain. He describes a 1-day history of a gnawing sharp pain, 7/10 in severity, located in the upper abdomen with radiation to the back. He also experienced nausea and intermittent vomiting 4–6 hours preceding emergency room evaluation. He is unable to tolerate oral intake.

Past medical history is pertinent for hypercholesterolemia, hypertension, glucose intolerance, hyperlipidemia, depression, anxiety, and metabolic

Clinical Presentation

There are multiple causes of acute abdominal pain that need to be considered in the evaluation of a patient with this clinical scenario. The differential diagnosis includes peptic ulcer disease, perforated viscous, pneumonia, diabetic ketoacidosis, renal colic, mesenteric ischemia, inferior myocardial infarction, abdominal aortic dissection, and acute pancreatitis.

This patient had an initial working diagnosis of acute pancreatitis based on his characteristic clinical picture of abdominal pain,

1. Assess Severity

Assessment of initial disease severity is an integral part of the evaluation of patients with acute pancreatitis (Figure 3). Although the majority of current practice guidelines recommend use of the Acute Physiology and Chronic Health Evaluation (APACHE) II score (score ≥8 for severe disease) (AGA, ACG, UK), this score is complex and requires collection of multiple variables, many of which are not routinely available in clinical practice. To address this issue, our group recently developed a

Fluid Resuscitation

Currently there is no evidence available from prospective controlled trials to support recommendations for aggressive fluid resuscitation for preventing complications in acute pancreatitis. The optimal rate, type, and volume of fluid for initial resuscitation remain unclear. At present, there are 2 active multicenter randomized clinical trials registered at Clinicaltrials.gov that focus on fluid resuscitation in acute pancreatitis. Our study, the Trial of Intravenous, Goal-directed Early fluid

Published Guidelines

Numerous practice guidelines have been published on the management of acute pancreatitis.1, 2, 3 Guidelines on medical management have been recently published from the AGA (2007) and ACG (2006). Updated recommendations on appropriateness of radiographic imaging were published by the ACR in 2005. Endoscopic guidelines are available from the ASGE (2005) and surgical recommendations exist from the SSAT (2004). Many of these guidelines overlap regarding their recommendations, which are summarized

Recommendations for This Patient

Initial clues to this patient's risk for a more complicated course included obesity, admission azotemia with elevated BUN (36 mg/dL), and the presence of SIRS (tachycardia with leukocytosis). For initial management, we pursue a strategy similar to that recommended for sepsis: all patients receive an initial volume challenge with bolus of 20 cc/kg over 60 to 90 minutes followed by continuous infusion of crystalloid (normal saline or Lactated Ringer's) at 3 cc/kg/h. Subsequent adjustments are

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    Additionally, significantly lower serum amylase and lipase levels have been observed in patients with alcoholic AP, perhaps as a result of poor pancreatic exocrine function [14]. Elevated triglyceride levels are also known to interfere with the serum amylase assay; conversely, both amylase and lipase may be elevated in patients with renal insufficiency without AP [16]. In equivocal presentations of pancreatitis without diagnostic clinical or biochemical findings, imaging is required for the diagnosis of AP [3].

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    There is a lack of established strict criteria for when drainage of the gall bladder is necessary, and in most circumstances it is questionable if it is required at all. It is commonly accepted in the veterinary70,157,158 and human literature61,159 that analgesia is a vital component of managing AP. Recently, the use of patient controlled analgesia in human gastroenterology has improved outcomes and reduced hospitalization times.159,160

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This article has an accompanying continuing medical education activity on page e57. Learning Objectives—At the end of this activity, the learner should be able to identify elements of the diagnosis and assessment of severity of acute pancreatitis, as well as guidelines for diagnosis and management of more complicated or prolonged disease.

Conflict of interest The authors disclose no conflicts.

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