Caught in the Middle: When Your Pancreas Throws a Fit

-Case-

A 47-year-old man with a history of alcohol use disorder presents to the ED the day after Thanksgiving with 12-hours of intractable nausea/vomiting, and epigastric abdominal pain radiating to his back. He mentions his symptoms started after his Thanksgiving feast where he drank a full case of beer by himself. He’s peri-febrile, tachycardic to 115, and in quite a bit of pain on your expert abdominal exam.

Abdominal pain, nausea, and vomiting are super common in the ED – so where do we go from here? What comes to mind with this presentation?

-Evaluation-

In this case, long-standing and large volume alcohol use with these acute abdominal symptoms should begin to point you towards our culprit: acute pancreatitis

  • When diagnosing pancreatitis, it boils down to 3 components: acute epigastric pain, lipase greater than 3x the upper limit of normal, and imaging demonstrating pancreatitis
    • To formally diagnose this disease, we need at least 2 of these 3 features. However, while in theory pancreatitis can be diagnosed with labs and a thorough physical exam alone, culturally, many hospital systems will still get a CT scan
  • With pancreatitis in mind, our evaluation includes basic labs (CBC, BMP, LFTs) and, the star of the show, lipase; often a CTAP can be helpful as well
  • Make sure to regularly monitor their vitals!

-Management-

  • For starters, let’s get our patient feeling a bit better! IV fluids and nausea medication are a great place to start – in fact, early fluids have been shown to decrease patient mortality
  • Making our patient NPO can give much needed bowel rest
    • However, early advancement of a low-fat diet within 24 hours of presentation if the patient stabilizes has been recently shown to reduce hospital LOS and risk of infection/necrosis
  • Please don’t forget to give our patient pain control! Our workup – especially the CT scan – can take a while so don’t let them suffer in the meantime. A great option for pain control in these patients is IV morphine
  • Prophylactic antibiotics are not always needed! Only in cases with necrosis should you opt for this – some great options are carbapenem, quinolone, ceftazidime, or cefepime + metronidazole

-Fast Facts-

  • Though rare and unspecific, pericolic bruising can be a sign of pancreatitis – particularly necrotic pancreatitis
  • A RUQUS (right upper quadrant ultrasound) has no true diagnostic utility for pancreatitis, but it can help find our most common cause of pancreatitis
  • Fluids, fluids, fluids! And don’t forget – pain control + nausea meds + NPO until stable to eat
  • Unsure of the causes of pancreatitis? Think “GET SMASHED”:

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Want to learn more? Read our in-depth study guide on this topic!

Cheers,

Tamir Zitelny, MD

-References-

  1. Boxhoorn L, Voermans RP, Bouwense SA, et al. Acute pancreatitis. Lancet. 2020;396(10252):726-734. doi:10.1016/S0140-6736(20)31310-6
  2. Duggan SN, Bluth MH, Carroll RE. Chronic pancreatitis. Lancet. 2024;403(10421):168-180. doi:10.1016/S0140-6736(24)02187-1
  3. Tenner S, Baillie J, DeWitt J, Vege SS. Acute pancreatitis: diagnosis and treatment. Drugs. 2022;82(3):261-275. doi:10.1007/s40265-022-01766-4
  4. Xiao AY, Tan ML, Wu LM, et al. Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Gastroenterology. 2021;160(3):744-754.e9. doi:10.1053/j.gastro.2020.10.020
  5. Li D, Tang J, Xia Q, et al. Incidence, severity, and mortality of post-ERCP pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc. 2020;92(4):709-722.e6. doi:10.1016/j.gie.2020.05.035

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