Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

Acute Pancreatitis 47

specific therapy

■Consider ERCP for biliary pancreatitis caused by gallstones in com-

mon bile duct (choledocholithiasis)

■Diagnosis suggested by elevated bilirubin or AST

■Consider endoscopic therapy for severe biliary pancreatitis; it may

reduce incidence of subsequent biliary sepsis

■Surgery rarely necessary early in course of disease, but may be indi-

cated for infected fluid collections or hemorrhage; later complica-

tions such as pseudocysts, ascites, & fistulas often surgically man-

aged

follow-up

■Dictated by clinical symptoms & extent of complications (eg, pseu-

docysts, fistulas, ascites)

■Full recovery expected for most pts w/ mild pancreatitis; patients

should be monitored until recovery complete; no long term follow-

up required for pts who exhibit full recovery & for whom clear cause

of pancreatitis has been identified & corrected

■Evaluate all pts should to identify cause of disease:

➣History of alcohol abuse

➣Cholelithiasis: assessed by abdominal US

➣Serum triglyceride assay

■Consider pts w/o identifiable cause to have idiopathic pancreatitis

■ERCP may be indicated to more carefully look for causes of obstruc-

tion (eg, strictures, common bile duct stones, cancers of ampulla of

Vater)

complications and prognosis

■Initial staging by clinical criteria (eg, Ranson, Glasgow, or APACHE

II) or CT useful in determining risk of complications:

■Shock: usually in first days after presentation:

➣Acute renal failure

➣Multiorgan failure

■Acute respiratory distress syndrome: usually 4–5 d after presentation

■Infection:

➣Usually >7 d after presentation

➣Evaluate fluid collections by abdominal CT followed by needle

aspiration w/ gram stain

➣Infected fluid collections surgically treated w/ drainage &

debridement

■Hemorrhage