Pancreatitis
Pancreatitis
Diagnosis of Pancreatitis by two of the three following criteria
Lipase > 2 times the upper limit of normal
Epigastric/RUQ tenderness
Radiologic evidence of pancreatitis
Unless it is a chronic and recurrent issue, imaging should be done (CT or ultrasound)
Lipid Panel Done
No evidence of billiary stone disease
Pain controlled with reasonable doses of IV medications
Can tolerate clear liquids
Normal Vital signs besides mild (<110) tachycardia
Serum Triglycerides > 500 mg/dl
Evidence of biliary stone disease or obstruction, elevated Alk Phos, Bili or stones or dilated CBD noted on US or CT.
Fever > 100.4 F
Necrosis or pseudocyst formation on CT or US
Requires PCA for pain control
Cannot tolerate any PO including clear liquids
Clear Liquid Diet. Advance Diet as Tolerated to a Low Fat diet
Fluid Resuscitation
IV LR (important). 10 ml / kg bolus followed by 1.5 ml / kg / hr maintenance. NS has worse outcomes.
Medication
Antiemetics
Droperidol, Compazine, Phenergan, Reglan, Zofran
Pain control
IV Acetaminophen 1000 mg Q8 hr
IV Opiate medications including morphine, hydromorphone and fentanyl may be used for this painful condition
ESP or Paravertebral block at T10 can achieve a Celiac Plexus Block by Proxy. It can be very effective (If Zeccola is available) see references below.
Labs
No specific labs are needed in mild acute pancreatitis.
Can consider Q8h Fingerstick Glucose measurement as some patients will develop an insulin insufficiency
No role for trending lipase
Disposition
Tolerating PO
Able to maintain adequate hydration off IV fluids
Pain controlled on reasonable doses of medications to be discharged on
Patients with alcoholic pancreatitis have recieved brief substance abuse counseling, offer of oral naltrexone
Stable vital signs
Follow up arranged with PCP after discharge
Unstable vital signs or worsening clinical condition
Significant lab or imaging abnormalities
Patient unable to take PO food, fluids or medications
Learning Link:
Chauhan G, Burke H, Srinivasan SK, Upadhyay A. Ultrasound-Guided Erector Spinae Block for Refractory Abdominal Pain Due to Acute on Chronic Pancreatitis. Cureus. 2022 Nov 23;14(11):e31817. doi: 10.7759/cureus.31817. PMID: 36579238; PMCID: PMC9783334.
Mantuani D, Josh Luftig PA, Herring A, Mian M, Nagdev A. Successful emergency pain control for acute pancreatitis with ultrasound guided erector spinae plane blocks. Am J Emerg Med. 2020 Jun;38(6):1298.e5-1298.e7. doi: 10.1016/j.ajem.2020.02.005. Epub 2020 Feb 5. PMID: 32081553.
Gopinath B, Mathew R, Bhoi S, Nayaka R, Muvalia G. Erector spinae plane block for pain control in patients with pancreatitis in the emergency department. Turk J Emerg Med. 2021 Jul 7;21(3):129-132. doi: 10.4103/2452-2473.320806. PMID: 34377871; PMCID: PMC8330605.