Miscellaneous
This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD Matthieu DeClerck, MD, Mike Weinstock, MD, and Cameron Berg, MD sit down to discuss the diagnostic criteria for acute pancreatitis. They discuss workup: the role of imaging to rule out gallstone pancreatitis. They go into risk stratification of acute pancreatitis as well as Initial management: pain control, IV fluids, nutrition. And ultimate disposition – when to go home? When to admit to a higher level of care? Pearls: Confirmatory CT scanning is rarely needed to confirm pancreatitis Amylase level is neither as sensitive or specific as lipase. Early feeding, has been shown to improve outcomes in patients with pancreatitis. DIAGNOSING PANCREATITIS Must meet 2 of the following 3 criteria: Clinical presentation that is consistent with pancreatitis - epigastric or upper abdominal pain, frequently radiating to the back often with associated with nausea and vomiting, A lipase level that is three times the upper lab limit of normal for a given assay. Do not order an amylase as it not as sensitive or specific for pancreatitis as lipase. The initial lipase level cannot predict outcomes of patients with pancreatitis and there's no utility in trending lipase levels A CT scan demonstrating pancreatic inflammation consistent with pancreatitis. Note: A CT is rarely needed to confirm pancreatitis but it is the gold standard when there is diagnostic uncertainty. Perform a RUQ ultrasound to rule out gallstone pancreatitis as the most common cause of pancreatitis in the United States is biliary. Patients with biliary tract obstruction will need an ERCP or MRCP urgently that many facilities cannot get 24/7. Obtain a triglyceride level as hypertriglyceridemia is the third most common cause of pancreatitis after alcohol and gallstones. MANAGEMENT Not all patients with acute pancreatitis require hospital stay. Consider the following factors before deciding on admission: Patient vital signs Clinical appearance Ability to perform ADLs Presences or absence of markers of end organ stability Patients with pancreatitis who are admitted should receive adequate fluid resuscitation in the form of 2-3L of IV crystalloid. Feed the patient orally as soon as possible as early enteral nutrition, rather than bowel rest, has been shown to greatly increase recovery. Patients with gallstone pancreatitis and pancreatitis secondary to hypertriglyceridemia require a higher level of care and should be referred appropriately. REFERENCES: Uhl, W. et al. 2003. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology. Tenner, S. 2013. American College of Gastroenterology Guidelines: Management of Pancreatitis. The American Journal of Gastroenterology.