Special Operations Forces Medical Handbook

4-82

Consult for worsening symptoms of pain or fever, or for signs of GI bleeding.

GI: Acute Pancreatitis

COL (Ret) Peter McNally, MC, USA

Introduction: Acute pancreatitis is an inammatory process of the pancreas usually associated with severe
pain in the upper abdomen. Gallstones and alcohol cause about 80-90% of acute pancreatitis. Most acute
cases will spontaneously resolve, but severe, chronic pancreatitis has a 50% mortality rate.

Subjective: Symptoms
Pain: located primarily in the epigastrium; may be localized to the right upper quadrant and radiate to the back;
pain reaches a maximum intensity rapidly over 10-20 minutes; described as unbearable, with little relief offered
by position. Patients frequently assume a fetal position. Nausea and vomiting are common.

Objective: Signs
Using Basic Tools: Inspection: Appears acutely ill; mental status may be depressed, especially if associated
with acute alcohol ingestion; fever, tachycardia and hypotension; ecchymosis along the anks (Grey Turner's
sign) or around the umbilicus (Cullen's sign) grave prognosis; jaundiced sclera (icterus); distended abdomen.
Auscultation: Decreased breath sounds from effusions or rales (ARDS)—grave prognosis; abdominal pain may
cause splinting and shallow respirations; absent bowel sounds.
Percussion: The abdomen is tympanic and diffusely tender.
Using Advanced Tools: Lab: CBC with differential for evidence of anemia and infection; save the red
top tube for future analysis for milky layer seen in hypertriglyceridemia. Pulse oximetry to evaluate ARDS.
Three-way radiograph of the abdomen for GI conditions (if available).

Assessment:
Use Ranson's Criteria* as a scoring system to predict severity of pancreatitis. See below.
Differential Diagnosis - Peptic ulcer disease, cholecystitis, ischemic bowel, aortic aneurysm, bowel
obstruction or perforation.

Plan:
Treatment - treat aggressively

1. NPO until pain resolved.


2. Pain control (avoid morphine - it may cause sphincter of oddi spasm, worsening pancreatitis).


3. Aggressive IV uid resuscitation (D5-Lactated Ringer's solution)


4. NG decompression if vomiting or distended


5. Antibiotic (cefotaxime 2 gm q 8 h IV) if patient appears septic (fever > 102° F, rigors, or jaundice)


6. Evacuation to hospital.

Patient Education
General: If gallstones caused the pancreatitis, then denitive treatment (surgical removal) and cure may
prevent future attacks. If the cause of pancreatitis is alcohol, abstinence is the key to prevent chronic relapsing
pancreatitis.
Diet: NPO during acute pancreatitis, then as tolerated after resolution.
Medications Shown to Cause Acute Pancreatitis: 6-mercaptopurine, azathioprine, sulfonamides (sul-
fasalazine and Bactrim), oral 5-aminosalicylic acid, antibiotics (metronidazole, tetracycline, and nitrofu-
rantoin), valproate, corticosteroids, furosemide, estrogens, Aldomet, pentamidine, didanosine.
Prevention: Cessation of all alcohol. Stop medicines proven to cause pancreatitis indenitely, see list above.
Normalize high triglyceride or calcium levels to prevent additional attacks.

Follow-up Actions
Evacuation/Consultation Criteria: These patients need urgent evacuation. Any rst attack of pancreatitis
needs gastroenterology consultation. Mild isolated cases should undergo primary search for etiology. A