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-

• Unsure of the causes of pancreatitis? Think “GET SMASHED”:
  • Gallstones (most common cause; only about 5% of patients with choledocholithiasis progress to gallstone pancreatitis)
  • EtOh (2nd most common cause)
  • Trauma (consider this in cases of blunt injury to the abdomen)
  • Steroids, Malignancy (often secondary to biliary tree mechanical blockages), Autoimmune (such as lupus), Scorpions (you will *probably* never actually see this clinically), Hypertriglyceridemia
  • ERCP (unfortunately a potential complication of this procedure)
  • Drugs (such as tetracyclines, azathioprine, thiazides, valproate, etc.)
• 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

Want to read more about this topic? Click ✨here✨ to read our in-depth Study Guide!