Hepatic Failure/GI/Endocrine Emergencies

Hypertriglyceridemia

Primary and secondary hypertriglyceridemia are increasingly recognized as causes of AP (5%–

22% reported).

If serum triglycerides are greater than 1000 mg/dL, hypertriglyceridemia should be suspected as

the cause.

Certain medications can cause pancreatitis through varied mechanisms. Drug-induced pancreatitis is

classified based on level of evidence and number of cases reported (Class 1, high level of evidence,

through Class 4, very low quality of evidence). Examples include:

Angiotensin-converting enzyme (ACE) inhibitors (Class 2)

Azathioprine, 6-mercaptopurine (Class 1)

HAART (highly active antiretroviral therapy) medications (e.g., didanosine) (Class 1, didanosine)

Valproic acid (Class 2)

Propofol (Class 4)

Malignancy – The presence of a pancreatic tumor blocking the main pancreatic duct should be suspected

in any patient older than 40 years with signs and symptoms of pancreatitis and no other apparent cause.

About 20% of AP cases are idiopathic.

Signs and symptoms

Abdominal pain

AP pain is usually located in the epigastric region or left upper quadrant; however, it may

radiate to the back, chest, or flank. Pain is typically constant and severe.

ii.

Gallstone pancreatitis–induced pain has been described as knifelike.

Nausea

According to the Acute Pancreatitis Classification Working Group definition of AP, serum lipase

(or amylase) concentrations at least 3 times the upper limit of normal are required for diagnosis.

Serum lipase is preferred for diagnosis because elevations in serum lipase concentrations are more

specific to the diagnosis of AP than elevations in amylase and serum lipase concentrations remain

elevated longer than amylase concentrations.

Amylase concentrations rise quickly (within a few hours) in AP; however, they return to

normal within a few days.

ii.

Amylase concentrations may remain normal in alcohol-induced AP and hypertriglyceridemia.

Imaging

Transabdominal ultrasonography should be done to confirm the diagnosis of AP for all patients.

Contrast-enhanced CT scans of the abdomen are more than 90% sensitive and specific in diagnosing

AP; however, routine use is unnecessary.

Contrast-enhanced CT and/or MRI should be used in patients with an unclear diagnosis or in

patients who do not improve after 48–72 hours to evaluate for complications.

Management

Hydration

Patients with AP need early aggressive volume resuscitation because they are volume depleted

for many reasons, including vomiting, reduced oral intake, third spacing of fluids because of

inflammatory response, and diaphoresis. In fact, it has been hypothesized that worsening pancreatic

hypoperfusion that develops from pancreatic inflammation in the setting of volume depletion leads

to pancreatic necrosis. Thus, early aggressive volume resuscitation may prevent the development

of pancreatic necrosis.