• Acute pancreatitis (AP) commonly leads to hospital admission.
• 75% of cases are due to alcohol or gallstones/biliary tract disease in the developed world.
• Multiple other causes of pancreatitis include:
  • Trauma, including ERCP;
  • Metabolic abnormalities (e.g., hypercalcemia and hypertriglyceridemia);
  • Viral infections (e.g., mumps, mononucleosis, hepatitis, coxsackie virus);
  • Pregnancy;
  • Lupus;
  • Other conditions that block duct (e.g., tumour, congenital);
  • Drugs, including antiretrovirals, chemotherapy, thiazide diuretics, sulfonamides, and azathioprine;
  • Scorpion sting;
  • Idiopathic
• Pancreatic necrosis occurs in 5-10% of patients and may progress to infected necrosis which is associated with mortality rates of up to 30%.

Diagnostic Criteria

2/3 of the following criteria:

• Abdominal pain (acute, severe, persistent, epigastric, +/- radiation to back)
  • 3 fold elevation from upper limit of normal of serum lipase (preferred) or amylase (various sources of amylase)
  • Risk of false negatives in early disease due to delayed elevation in levels (4-8h from inflammation onset).
• Findings characteristic of AP on imaging (US/CT)

Laboratory investigations

• Serum lipase
• CBC
• Electrolytes
• Glucose level
• Calcium
• Renal function
• Liver function
• C Reactive Protein (peaks at 36-72 hours)

A diagnosis of AP is often made based on history, physical exam and serum lipase level. Imaging may be less urgent, occurring later in the work-up to determine the etiology. If no access to the necessary imaging modalities, patient transfer may be required.

Imaging

• All patients should undergo an ultrasound to look for stones in the biliary tract.
• CT has limited utility initially:
  • Local complications may not be appreciable until 48-72 hours after onset.
  • Uses:
    • Diagnosis uncertain and/or to narrow a broad differential.
    • Assessment of potential local complications – cyst, necrosis, infarction – and pleural effusion.
    • Contrast is recommended unless contraindications.
  • Magnetic resonance cholangiopancreatography (MRCP) – elevated liver enzymes and an inconclusive or normal ultrasound of the common bile duct.
  • Chest X-ray for potential pleural effusions and infiltrates if symptomatic.

Complications

• Due to release of pancreatic enzymes locally and systemically.
  • Necrotizing pancreatitis – may become infected.
  • Systemic inflammatory response
    • Pulmonary complications
    • Metabolic complications (Ca++, increased BS)
    • Coagulopathy
    • Multi-organ failure
    • Sepsis, shock

• Pancreatic pseudocyst or walled-off necrosis occur weeks after initial onset.

Evaluation of disease severity

• Presence of systemic inflammatory response syndrome (SIRS) or qSOFA
• Scoring systems serve to support the clinical assessment.
• Patients often present soon after symptom onset and prior to the development of complications making it challenging to gauge disease severity on initial assessment.
• BISAP Score – parameters used to calculate score can be obtained in ED unlike older Ranson’s Criteria which requires parameters obtained at 48 h from time of admission:
  • BUN > 8.92 mmol/L
  • Impaired Mental Status
  • > 2 SIRS Criteria
  • Age > 60 years
  • Pleural effusion present
  • Score < 2 = mortality of 1.9%
• Harmless Acute Pancreatitis Score (HAPS):
  • NB: Developed primarily by chart review (retrospective) studies.
  • Peritonitis (rebound tenderness/guarding)
  • Cr > 177 mmol/L
  • Hematocrit > 43% (male) or 39.6% (female)

• BISAP Score – MDCalc
• SIRS Criteria – MDCalc
• qSOFA – MDCalc
• HAPS – MDCalc

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2. Greenberg JA, Hsu J, Bawazeer M, et al. Clinical practice guideline: Management of acute pancreatitis. Can J Surg. 2016;59(2):128-140. 

   
   

3. Acute Pancreatitis – an overview. ScienceDirect Topics. Accessed January 3, 2021.

   
   

4. Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020. Accessed November 23, 2020.

   
   

5. Waller A, Long B, Koyfman A, Gottleib M. Acute pancreatitis: Updates for emergency clinicians. J Emerg Med. 2018;55(6):769-779. 

   
   

6. Swaminathan A. Acute pancreatitis. CORE EM. Published March 14, 2018. Accessed January 3, 2021.

   
   

7. BISAP Score for Pancreatitis Mortality. MDCalc. 

   
   

8. Harmless Acute Pancreatitis Score (HAPS). MDCalc.