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Case 79: Pancreatitis

A 79 year old woman is admitted with 18 hours of epigastric pain and vomiting. Her amylase is 3769 and lipase is 6023. Her temperature is 39.2 degrees and bilirubin is 76. An ultrasound is followed by a CT scan (shown below).

1. What is the likely cause for her pancreatitis based on the CT?

There is a large laminated stone within the gallbladder (B) and a column of similar but smaller stones seen within the common bile duct (A). This is the most likely cause of her pancreatitis.

Click on the image for assistance

2. How would you determine the severity of her pancreatitis?

There are mulitple scoring systems for predicting the severity and outcome of an attack of pancreatitis. Widely used clinical systems include the Ranson score, Glasgow score and APACHE II. Measurement of C-reactive protein as a guide to the severity of systemic inflammation has also been validated as a predictor of severity.

There are also imaging scores based on CT (Balthazar computed tomography severity index CTSI) or MRI of the pancreas. These examine for extent of oedema, necrosis and peripancreatic inflammation.

Basic investigations (liver function, calcium, CRP, FBE, glucose and renal function) should be measured on all patients. In those with suspected severe pancreatitis further investigations should be directed at detecting or excluding complications such as sepsis and respiratory failure. Early imaging with CT or MRI does not often change management and need not be routine.

3. What specific therapies have been shown to improve outcome for severe pancreatitis?

Early ERCP (within 72 hours at most) and stone extraction and/or stenting has been demonstrated to improve the outcome of severe gallstone pancreatitis particularly if it is associated with cholangitis.
Prophylactic broad spectrum intravenous antibiotics such as imipenem or meropenem have also been demonstrated to improve outcome. They are indicated in severe attacks particularly where sepsis is considered even without proven infected necrosis. Many antibiotics probably do not effectively penetrate the inflamed pancreas and are therefor of little value (ampicillin, gentamicin, metronidazole).

Suggested reading: UK guidelines for the management of acute pancreatitis, Gut 2005;54(Suppl III):iii1–iii9.