This morning, Dr. Lainey Flatow-Trujillo, one of our amazing R2s, shared with us the case of a young woman with a history of biliary colic who presented with 5 days of epigastric pain radiating to the back and an initial lipase > 3000. The group quickly arrived at the diagnosis of gallstone pancreatitis.
We then spent some time delving into the management of acute pancreatitis. Because gallstones are the most common cause, an abdominal US is required. Patients in whom the diagnosis is unclear or whose symptoms persist may benefit from a CT with contrast. In patients without gallstones or heavy alcohol use, other etiologies, such as hypertriglyceridemia, hypercalcemia, and medications, should be investigated. Other less common causes include post-ERCP, traumatic, infectious, and autoimmune pancreatitis.
The key to management is aggressive hydration (e.g., 4 liters in the first 24 hours). Patients are often volume-depleted, so a bolus followed by a continuous infusion (e.g., 2 L up front followed by 100 mL/hr for 20 hr) is reasonable. IV analgesics are indicated. Oral (or at least parenteral) feeding should be started as soon as the patient is able to tolerate it, as this has been shown to decrease the risk of complications such as infection.
ERCP, a therapeutic procedure, is indicated when there is concern for ascending cholangitis or persistent obstruction. Otherwise, MRCP or EUS can be considered (not required for mild episodes). Laparoscopic cholecystectomy is recommended during the same admission to reduce the risk of recurrence for mild cases of gallstone pancreatitis. Debridement of necrosis, if present, should be avoided unless the patient is unstable.
Thank you to Dr. Wilson Kwong, our expert discussant, for offering his clinical pearls!
Medical Spanish Word of the Day: la piedra (colloquial), el cálculo (formal) = stone