Case 3.5 – Pancreatitis

Key history features:

• Alcohol consumption: Quantity, frequency, and duration - chronic alcohol use is a major risk factor
• Gallstone history: Previous biliary colic, cholecystitis - gallstones cause ~40% of cases
• Trauma: Recent abdominal trauma, particularly blunt epigastric injury
• Medications: Corticosteroids, thiazides, furosemide, azathioprine, valproate, sulfonamides
• Pain characteristics: Severe epigastric pain radiating to back, constant, worse supine, relieved sitting forward
• Associated symptoms: Nausea, vomiting, anorexia
• Previous episodes: Details of prior pancreatitis and identified cause
• Other causes: Hypercalcemia, hypertriglyceridemia, recent ERCP, family history

Physical examination findings:

• General: Distress, pallor, diaphoresis, dehydration
• Vital signs: Hypotension, tachycardia, tachypnea, fever, hypoxia
• Abdominal exam: Epigastric tenderness, guarding, distension, reduced bowel sounds, peritonism
• Cullen's sign: Periumbilical bruising (retroperitoneal hemorrhage)
• Grey-Turner sign: Flank bruising (retroperitoneal hemorrhage)
• Respiratory: Reduced breath sounds at bases (pleural effusions)
• Jaundice: Suggests biliary obstruction

Note: Cullen's and Grey-Turner signs indicate hemorrhagic pancreatitis and carry poor prognosis, but are rare and late findings.

Early Complications (first 1-2 weeks):

• SIRS/sepsis: Inflammatory response causing systemic illness
• Hypovolemia: Third-space fluid losses requiring aggressive resuscitation
• Organ failure:
  • Respiratory: ARDS, pleural effusions, hypoxia
  • Renal: Acute kidney injury from hypovolemia/ATN
  • Cardiovascular: Shock, arrhythmias
• Metabolic: Hypocalcemia, hyperglycemia, hypomagnesemia
• GI bleeding: Stress ulceration, variceal bleeding

Late Complications (after 1-2 weeks):

• Pancreatic necrosis: Devitalized pancreatic tissue, may become infected
• Infected necrosis: High mortality, requires antibiotics/drainage
• Pseudocyst: Fluid collection that persists >4 weeks
• Abscess: Localized infected fluid collection
• Chronic pancreatitis: Permanent structural damage after recurrent episodes

Essential investigations:

• Serum lipase: >3x upper limit of normal is diagnostic (more specific than amylase)
• FBC: WCC (infection/SIRS), Hb (hemorrhage), Hct (hemoconcentration predicts severity)
• CRP: Elevated, useful for monitoring and predicting necrosis
• U&E: Assess renal function, electrolytes (hypovolemia effects)
• Glucose: Hyperglycemia common (pancreatic endocrine dysfunction)
• LFTs: ALT >150 U/L suggests gallstone etiology; assess bilirubin
• Calcium: Hypocalcemia indicates severe disease
• ABG: Assess oxygenation, acid-base status, lactate
• CXR: Pleural effusions, pulmonary infiltrates, exclude perforation
• Abdominal ultrasound: Identify gallstones, bile duct dilatation, pancreatic changes

Consider: CT abdomen with contrast after 48-72 hours if severe disease (assess necrosis, complications), triglycerides, serum calcium if recurrent/etiology unclear.

Immediate management:

• Nil by mouth (NBM): Pancreatic rest in acute phase
• Aggressive IV fluid resuscitation:
  • Crystalloid (Hartmann's or normal saline) 250-500 mL/hr initially
  • Target urine output >0.5 mL/kg/hr
  • Monitor for fluid overload (risk of ARDS)
  • Early aggressive fluids reduce organ failure and mortality
• Opioid analgesia:
  • Morphine or fentanyl IV (opioids do NOT worsen pancreatitis)
  • Titrate to pain control
  • PCA (patient-controlled analgesia) if available
• Antiemetics: Ondansetron, metoclopramide
• Oxygen: If hypoxic (SaO2 \<95%)
• Monitor: Vital signs, fluid balance, urine output
• Antibiotics: NOT routinely indicated unless infected necrosis/cholangitis suspected

Clinical indicators of severe pancreatitis:

• Persistent organ failure (\>48 hours): respiratory, cardiovascular, renal
• SIRS criteria: temp >38°C or <36°C, HR >90, RR >20, WCC >12 or <4
• Hemoconcentration (Hct >44%) or failure to decrease with fluids
• Rising CRP (\>150 mg/L at 48 hours)
• Hypocalcemia (\<2 mmol/L)
• Clinical deterioration despite resuscitation

Ranson's Criteria (Modified Imrie/Glasgow)

Score ≥3 indicates severe pancreatitis. Each criterion = 1 point.

APACHE II

Complex scoring system using multiple physiological parameters. Score >8 indicates severe disease. Parameters include age, vital signs, GCS, and laboratory values. Calculated using online tools or ICU charts.

ICU retrieval process:

1. Recognize need for ICU: Severe pancreatitis with organ failure, persistent hypotension despite fluids, respiratory failure, deterioration
2. Contact Medical Retrieval Service: Call state-based retrieval coordination number (e.g., 1800 number for regional services)
3. Provide clinical information: Patient details, vital signs, diagnosis, interventions performed, current support requirements
4. Coordinate ICU bed: Retrieval service coordinates with tertiary center ICU for bed availability
5. Stabilization: Continue aggressive resuscitation while awaiting team:
   • Maintain IV fluid resuscitation
   • Optimize oxygenation (may need CPAP/intubation)
   • Adequate analgesia
   • Insert NGT if significant ileus/vomiting
   • Catheterize for accurate fluid monitoring
6. Retrieval team assessment: Critical care team (doctor, nurse, paramedic) stabilizes patient for transfer
7. Transfer: Air or road ambulance to tertiary ICU
8. Documentation: Detailed handover notes, copies of investigations, imaging