eMedicine Specialties > Emergency Medicine > Gastrointestinal

Pancreatitis: Follow-up

Author: Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Coauthor(s): Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Contributor Information and Disclosures

Updated: Jan 26, 2009

Follow-up

Further Inpatient Care

  • Medical treatment consists of the following:

    • Fluid resuscitation and hydration: Patients with acute pancreatitis lose a large amount of fluids to third spacing into the retroperitoneum and intra-abdominal area. These fluids have to be replaced promptly within the first 24 hours with both crystalline and colloid solutions, sometimes reaching 10 L.
    • Central venous pressure, pulmonary artery wedge pressure, and urine output (>0.5 mL/kg/h) can be followed up as markers of adequate hydration.
    • The previously followed rule of NPO has changed, and prospective randomized controlled trials have showed that enteral tube feeding is superior to parenteral nutrition to avoid malnutrition and reverse the catabolic state of these patients.
    • Adequate analgesia: Opiate derivatives and epidural analgesia can be added if needed.
    • Antibiotic coverage is needed to prevent gram-negative sepsis.
  • Surgery is an option in cases with complications of pancreatitis such as acute necrotizing pancreatitis where the necrotic phlegmon is excised to limit the source of sepsis, or in cases of hemorrhagic pancreatitis where the process has eroded into one of the vessels supplying the pancreas and a surgical control of bleeding is warranted.

Further Outpatient Care

  • The patient should be monitored routinely with physical examination and amylase and lipase assays.

Transfer

  • Transfer patients with Ranson scores of 0-2 to a hospital floor.  
  • Transfer patients with Ranson scores 3-5 to an intensive care unit.  
  • Transfer patients with Ranson scores higher than 3 to an intensive care unit with emergency surgery as a possibility, depending on the patient's progress and findings on abdominal CT scanning.

Complications

  • Infected pancreatic necrosis may result from seeding of bacteria into the inflammation.
  • An acute pseudocyst is an effusion of pancreatic juice that is walled off by granulation tissue after an episode of acute pancreatitis.
  • Hemorrhage into the GI tract retroperitoneum or the peritoneal cavity is possible because of erosion of large vessels.
  • Intestinal obstruction or necrosis may occur.
  • Common bile duct obstruction may be caused by a pancreatic abscess, pseudocyst, or biliary stone that caused the pancreatitis.
  • An internal pancreatic fistula from pancreatic duct disruption or a leaking pancreatic pseudocyst may occur.

Prognosis

  • Ranson developed a series of different criteria for the severity of acute pancreatitis.9 This scoring system is still widely used:
    • Present on admission

      • Older than 55 years
      • WBC higher than 16,000 per mcL
      • Blood glucose level higher than 200 mg/dL
      • Serum lactate dehydrogenase (LDH) level more than 350 IU/L
      • SGOT level (ie, aspartate aminotransferase [AST]) greater than 250 IU/L
    • Developing during the first 48 hours
      • Hematocrit fall more than 10%
      • BUN level increase more than 8 mg/dL
      • Serum calcium level less than 8 mg/dL
      • Arterial oxygen saturation less than 60 mm Hg
      • Base deficit higher than 4 mEq/L
      • Estimated fluid sequestration higher than 600 mL
  • Each of the above adds a point to the score.
  • A Ranson score of 0-2 has a minimal mortality rate, and the patient is admitted to the regular ward for medical therapy and support.
  • A Ranson score of 3-5 has a 10-20% mortality rate, and the patient should be admitted to the intensive care unit.
  • A Ranson score after 48 hours higher than 5 has a mortality rate of more than 50% and is associated with more systemic complications.
  • Other scoring systems are Glasgow, Imrie, and APACHE II.

Patient Education

  • Educate patients about the disease and advise them to avoid alcohol in binge amounts and to discontinue any risk factor, such as fatty meals and abdominal trauma.
  • For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education article, Pancreatitis.
 


More on Pancreatitis

Overview: Pancreatitis
Differential Diagnoses & Workup: Pancreatitis
Treatment & Medication: Pancreatitis
Follow-up: Pancreatitis
References
[ CLOSE WINDOW ]

References

  1. Granger J, Remick D. Acute pancreatitis: models, markers, and mediators. Shock. Dec 2005;24 Suppl 1:45-51. [Medline].

  2. Banks PA. Epidemiology, natural history, and predictors of disease outcome in acute and chronic pancreatitis. Gastrointest Endosc. Dec 2002;56(6 Suppl):S226-30. [Medline].

  3. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. May 18 2006;354(20):2142-50. [Medline].

  4. Akhtar AJ, Shaheen M. Extrapancreatic manifestations of acute pancreatitis in African-American and Hispanic patients. Pancreas. Nov 2004;29(4):291-7. [Medline].

  5. Whitcomb DC, Yadav D, Adam S, Hawes RH, Brand RE, Anderson MA, et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008;8(4-5):520-31. [Medline].

  6. Balthazar EJ. Staging of acute pancreatitis. Radiol Clin North Am. Dec 2002;40(6):1199-209. [Medline].

  7. Jacobson DG, Curington C, Connery K, Toskes PP. Trypsin-like immunoreactivity as a test for pancreatic insufficiency. N Engl J Med. May 17 1984;310(20):1307-9. [Medline].

  8. Chowdhury RS, Forsmark CE. Review article: pancreatic function testing. Aliment Pharmacol Ther. Mar 2003;17(6):733–50. [Medline].

  9. Imrie CW. Prognostic indicators in acute pancreatitis. Can J Gastroenterol. May 2003;17(5):325-8. [Medline].

  10. Bernhardt A, Kortgen A, Niesel HCh, Goertz A. [Using epidural anesthesia in patients with acute pancreatitis--prospective study of 121 patients]. Anaesthesiol Reanim. 2002;27(1):16-22. [Medline].

  11. Calleja GA, Barkin JS. Acute pancreatitis. Med Clin North Am. Sep 1993;77(5):1037-56. [Medline].

  12. Kemppainen E, Hedstrom J, Puolakkainen P, et al. Increased serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex values identify endoscopic retrograde cholangiopancreatography induced pancreatitis with high accuracy. Gut. Nov 1997;41(5):690-5. [Medline].

  13. Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ. Jun 12 2004;328(7453):1407. [Medline].

  14. Moscati RM. Cholelithiasis, cholecystitis, and pancreatitis. Emerg Med Clin North Am. Nov 1996;14(4):719-37. [Medline].

  15. Neoptolemos JP, Kemppainen EA, Mayer JM, et al. Early prediction of severity in acute pancreatitis by urinary trypsinogen activation peptide: a multicentre study. Lancet. Jun 3 2000;355(9219):1955-60. [Medline].

  16. Pannala R, Chari ST. Autoimmune pancreatitis. Curr Opin Gastroenterol. Sep 2008;24(5):591-6. [Medline].

  17. Plock JA, Schmidt J, Anderson SE, Sarr MG, Roggo A. Contrast-enhanced computed tomography in acute pancreatitis: does contrast medium worsen its course due to impaired microcirculation?. Langenbecks Arch Surg. Apr 2005;390(2):156-63. [Medline].

  18. Schwartz Gr, et al. Acute pancreatitis. In: Principles and Practice of Emergency Medicine. Vol 2. 1992:1782-6.

  19. Sharma VK, Howden CW. Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis. Am J Gastroenterol. Nov 1999;94(11):3211-4. [Medline].

  20. Steer ML. Classification and pathogenesis of pancreatitis. Surg Clin North Am. Jun 1989;69(3):467-80. [Medline].

  21. Taylor SL, Morgan DL, Denson KD, Lane MM, Pennington LR. A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ system score in predicting patient outcome in pancreatitis. Am J Surg. Feb 2005;189(2):219-22. [Medline].

  22. Trede M, Carter DC. Acute pancreatitis. In: Surgery of the Pancreas. 1993:161-259.

  23. Werner J, Feuerbach S, Uhl W, Buchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut. Mar 2005;54(3):426-36. [Medline].

  24. Wu SD, Zhang ZH, Jin JZ, Kong J, Wang W, Zhang Q, et al. Effects of narcotic analgesic drugs on human Oddi's sphincter motility. World J Gastroenterol. Oct 1 2004;10(19):2901-4. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Ghattas Khoury, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.