CanadiEM - By Doran Drew - June 28, 2016
"The trauma bay is swamped, rooms are a scarce commodity and inpatient beds are in even more dubious supply. You set your coffee down and prepare to go see your newest patient, a 65-year-old male complaining of abdominal pain. Flipping through his chart, you note that he is tachycardic at 113 bpm and febrile with a temperature of 38.1 °C. En route to the patient’s bed, your nursing colleague stops to tell you that the patient looks terrible. Your patient is a portly man of ruddy complexion. His face is flushed and sweat beads his brow. The history is non-contributory and physical exam reveals only epigastric tenderness without peritoneal signs. You add acute pancreatitis to your lengthy differential.
Patients with acute pancreatitis fall somewhere on a wide spectrum of severity, with a natural history ranging from benign to deadly. The appropriate disposition for these patients in today’s climate of gridlocked hospital beds is often ambiguous. Recent posts have provided tips on remembering Ranson’s Criteria and the BISAP score. This post takes a broader look at pancreatitis, with discussion of its etiology and pathophysiology, diagnosis, risk stratification, and acute management...
Clinical Pearls
- Key considerations for an emergency physician interpreting a patient’s history are prior gallstones, excessive ethanol use, recent ERCP and use of ACE inhibitors, valproic acid or HAART therapy.
- Lipase is superior to amylase in making the diagnosis of pancreatitis.
- Neither lipase nor amylase are useful in predicting patient outcomes.
- Biliary tree ultrasound is important in pancreatitis, as gallstone pancreatitis will be managed surgically.
- BALI and BISAP risk-stratification tools lend themselves to use in the emergency department.
- Patients with a BISAP score ≥2 and/or a BALI score ≥3 are at significantly elevated risk of mortality and should be closely monitored."