Approach to the Management

The first step in the management of acute pancreatitis is to make the correct diagnosis. This should be done while the patient is receiving resuscitation with intravenous (IV) flu-

FIGURE 136-1. Contrast enhanced computed tomography (CT) scan in acute pancreatitis. A, Contrast enhanced CT scan in mild pancreatitis. B, Contrast enhanced CT scan in severe necrotizing pancreatitis. Note the unenhanced pancreatic parenchyma (arrows) indicative of pancreatic necrosis.

TABLE 136-3. Ranson's Criteria for Severity of Pancreatitis*

At Admission

During Initial 48 Hours

Age > 55 years

White blood cell count > 16,000/mm3

Glucose > 200 mg/dL

Lactate dehydrogenase > 350 IU/L

Aspartate aminotransferase > 250 U/L

Hematocrit decrease of > 10 mg/dL Blood urea nitrogen increase of > 5 mg/dL

Calcium < 8 mg/dL PaO2 < 60 mm Hg Base deficit > 4 mEq/L Fluid sequestration > 6 L

*A score of 6 or more correlates with > 60% mortality.

ids in the emergency room. The correct diagnosis is important in patients presenting with severe disease, because conditions such as acute mesenteric ischemia and acute cholecystitis may present in a similar fashion and have a different management. Once the diagnosis of acute pancreatitis is established, an attempt should be made to define the etiology of the acute attack. This is important since the

TABLE 136-4. CT Finding in Acute Pancreatitis and CT Severity Index

Staging Score

A. Normal 0

B. Focal or diffuse enlargement of gland 1

C. As B plus involvement of peripancreatic fat 2

D. As C plus single, ill defined fluid collection 3

E. As D plus a 2 ill-defined fluid collections and/or intrapancreatic gas 4

Degree of Necrosis (%) (Nonenhancement with IV contrast) Score

< 33 of pancreas 2

33 to < 50 of pancreas 4

a 50 of pancreas 6

From Balthazar et al, 1989.

CT = computed tomography; IV = intravenous.

CT score + necrosis score = CT Severity Index (CTSI).

management of acute biliary pancreatitis may include urgent endoscopic retrograde cholangiography (ERCP). We perform an ultrasound scan at admission on patients with suspected biliary pancreatitis, the severity of acute pancreatitis should be assessed clinically and by scoring systems such as the APACHE II. Patients who have severe acute pancreatitis should receive a contrast enhanced CT scan. It confirms the clinical diagnosis, establishes severity, and documents the extent of necrosis. MRI and serologi-cal markers such as CRP may prove to be useful markers of disease severity and necrosis. Patients with severe acute pancreatitis should be admitted to an intensive care unit whereas mild pancreatitis can be managed on a regular medical floor (Figure 136-2).

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