Acute Pancreatitis: Case Report and the Importance of Early Prediction of Severity

INTRODUCTION: Acute Pancreatitis (AP) was the third most common GI diagnosis in 2012, resulting in approximately 275,000 admissions and costing about $2.6 billion. It remains a disease characterized by significant morbidity and mortality, and to this day, there is not a medication to treat it. Most care is supportive. Establishing the severity of the disease accurately is important in order to triage patients to the correct level of care to decrease rate of complications, mortality, and potentially shorten duration of stay. CASE REVIEW: 30yo male with history of alcohol use/abuse, with prior episode of pancreatitis 5mo earlier, presented to the Emergency Department with sudden onset of epigastric pain radiating to the back, nausea, vomiting. Patient’s last drink was 4 days prior, admitting to binging over the weekend. Initial VS: HR in 110s-120s, RR 20. BP 162/105. Initial remarkable labs: WBC 18.3, Na 133, K 3.0, CO2 15, AG 25,BG 149 lipase 2610. On physical exam, patient was uncomfortable with a diffusely tender abdomen. He appeared hypovolemic. He received 2L NS in ED. Patient was admitted to the medical floor and started on 250mL/hrof LR, given Dilaudidfor pain control and placed NPO. 8 hours after admit, patient acutely decompensated. Repeat VS BP 92/60, HR 159, RR 25. Abdomen was taught on exam. Patient was was transferred to the ICU for further management. Repeat labs now showing H&H 21&61, K 5.6, CO2 9, AG 21, Cr 1.35, CA 6.5, Mag 1.6, lactate 8.9. Patient was started on a bicarbonate drip, received calcium gluconate and 10 units of NPH, and D50 injection. A Foley catheter was inserted with an estimated bladder pressure of 12. Despite measures, patient’s acidosis and renal failure worsened and 3 hours later, patient was transferred to PPMC ICU for further management. DISCUSSION: Most authors of past and current guidelines recommend physicians to predict the severity of AP early on to guide the triage of patients. A multitude of predictive models have been developed to predict the severity of AP based upon clinical, laboratory, and radiologic risk factors, various severity grading systems, and serum markers {2] Some of these can be performed on admission to assist in triage of patients, while others can only be obtained after the first 48 to 72 hours or later. However these predictive models have low specificity, which, when coupled with the low prevalence of severe AP, results in low positive predictive values. •A CRP level above 150mg/L at 48 hours is associated with severe pancreatitis with an 80% sensitivity. •A BUN level of 20mg/dLon admission is also associated with an increased risk of death, as is an increase in BUN at 24hrs. •Ranson’scriteria and Apache II scores are 2 scoring tools frequently used in inpatient medicine. •Whilst an Apache II score has a median sensitivity of 100% and can be used on admission and repeated daily, a Ranson‘sscore \u3e 2 has a sensitivity and a specificity in the 80s, and has to be calculated at 48hours. •An Apache II score \u3e 8 and up-trending scores suggest a severe episode5 •Other scoring systems include SIRS, BISAP, CTSI.https://digitalcommons.providence.org/milwaukie_family/1005/thumbnail.jp