Pancreatitis

CausesGET SMASH’D

• Gallstones

• Ethanol (alcohol)

• Trauma (blunt abdominal trauma)

• Steroids

• Mumps (and other infections, e.g. Coxsackie, EBV)

• Autoimmune pancreatitis

• Scorpion bites (rare, e.g. Tityus species)

• Hyperlipidaemia (TGs usually >11 mmol/L)

• Drugs (ACE inhibitors, GLP-1/DPP-4 inhibitors, sulfonamides, etc.)

Acute Pancreatitis

Initial Investigations

• Lipase (>3× normal) is more specific than amylase for acute pancreatitis.

• LFTs to detect possible gallstone aetiology (↑ ALP, GGT)

• Serum TGs if hypertriglyceridaemia is suspected

• Calcium (hypocalcaemia can be seen in pancreatitis)

• Abdominal Ultrasound to check for gallstones or biliary dilation

Management

General Principles

• Hospital Admission: All cases of moderate to severe acute pancreatitis require admission for supportive care.

• IV Fluids: Goal-directed fluid resuscitation (e.g. Hartmann’s solution), aiming for urine output >0.5 mL/kg/hr

• Analgesia: IV morphine or fentanyl (avoid pethidine due to toxic metabolites)

• Antiemetics if needed

• Feeding:

  • Encourage early oral feeding as tolerated (reduces hospital stay)

  • If NBM >72 hours, use enteral feeding via nasogastric tube (avoids TPN)

  • Reserve TPN only if enteral routes are not feasible

Specific Scenarios

• Gallstone Pancreatitis:

  • Early cholecystectomy (ideally during the same hospital admission) to prevent recurrence

• Alcohol-Induced:

  • Cease alcohol; referral to alcohol cessation programs

Prophylactic Antibiotics

• Not recommended unless there is proven or strongly suspected infected necrosis or sepsis

Complications

Early (within 1–2 weeks)

• Hypovolaemia / shock from massive fluid shifts

• ARDS (acute respiratory distress syndrome)

• Renal failure (acute kidney injury due to hypoperfusion, severe sepsis)

Late (after 2–4 weeks)

• Pancreatic Pseudocyst: Fluid collection; may resolve spontaneously, endoscopic/percutaneous drainage if symptomatic

• Pancreatic Necrosis: Drain if infected or symptomatic; antibiotics if infection proven

• Fistulas, pseudoaneurysm formation (risk of haemorrhage)

• Walled-Off Necrosis: Typically after 4 weeks, may need surgical or endoscopic intervention if symptomatic

Chronic Pancreatitis

Causes

• Chronic Alcohol Use (most common in Australia)

• Hereditary Pancreatitis

• Recurrent Severe Acute Pancreatitis

• Autoimmune Disease (IgG4-related disease)

Management

• Pain Management

  • Cease Alcohol (absolute requirement for slowing progression)

  • Pancreatic Enzyme Supplements if malabsorption or if enzyme replacement helps pain

  • Refractory Pain: Consider ERCP with pancreatic duct stenting or lithotripsy if ductal stones; surgery if needed

• Malabsorption

  • Pancreatic Enzyme Replacement for steatorrhoea, vitamin malabsorption (especially fat-soluble vitamins A, D, E, K)

  • Vitamin D supplementation until nutritional status normalises

  • Dietitian Referral for tailored nutrition advice

Complications

• Osteoporosis: Chronic malabsorption, vitamin D deficiency → screen and manage

• Diabetes: Exocrine insufficiency can extend to endocrine insufficiency → check HbA1c, fasting BGL annually for early detection

Key Points

• Always consider gallstones and alcohol as leading causes for acute pancreatitis in adults.

• Lipase is the preferred enzyme test for diagnosis over amylase.

• Early cholecystectomy advised in gallstone pancreatitis to prevent recurrence.

• Chronic pancreatitis leads to chronic pain, malabsorption, and risk of insulin-dependent diabetes.

• Smoking cessation recommended, as smoking exacerbates pancreatic damage.