Pinpointing pancreatitis difficult, but key to good outcomes

Several review papers help internists identify patients with pancreatitis who are most likely to progress to severe disease and how to best manage their care.

While 80% of acute pancreatitis cases never progress beyond mild disease and a short hospital stay, a minority of patients face life-threatening risks, including organ damage and necrosis.

And therein lies the conundrum for hospital physicians—how to identify the patients most likely to progress to severe disease and how to best manage their care? Several recent review papers have attempted to shed some light on the management and epidemiology of this relatively common inflammatory disorder.

To identify patients at higher risk of developing severe pancreatitis physicians should rely upon their clinical judgment watching out for the presence of systemic inflammatory response syndrome alo
To identify patients at higher risk of developing severe pancreatitis, physicians should rely upon their clinical judgment, watching out for the presence of systemic inflammatory response syndrome along with other risk factors. Image by Photodisc

Hospitalizations for acute pancreatitis have increased in recent years in line with rising rates of obesity and gallstones, reaching 275,000 U.S. admissions in 2012, a 15% increase from 2003, according to data published in the December 2015 Gastroenterology. The median length of stay was three days; the in-hospital mortality rate was just under 1%. But the mortality rate for those who develop organ failure is far higher, with roughly one-third dying and a similar percentage developing pancreatic necrosis, according to a meta-analysis of 14 studies published in 2010 in Gastroenterology.

“We take it so seriously because any case—and again it's difficult to predict—can be a severe case,” said James Haddad, MD, ACP Member, a general internist and part of the internal medicine staff at Naval Hospital Jacksonville in Florida. (Of note, Dr. Haddad's views are his own and do not necessarily reflect the views of the U.S. military.)

With no drug available to thwart the worsening of acute pancreatitis, hospital physicians are left with limited tools to support a patient while the condition runs its course. Adding to the challenge are debates about the existing risk-scoring methods and uncertainties about how aggressively to administer fluids for patients who might be more vulnerable to severe pancreatitis.

Identifying vulnerable patients

Several scoring systems of varying complexity attempt to identify patients with a higher potential of developing severe disease. But Chris Forsmark, MD, FACP, lead author of a review about acute pancreatitis published in the Nov. 17, 2016, New England Journal of Medicine (NEJM), is discouraging about their benefit.

They are frequently cumbersome and result in a high rate of false positives, which means that some patients will be transferred to a more intensive and costlier level of care that's not needed, he said. “That is, many folks with a high score do just fine,” said Dr. Forsmark, who is chief of the division of gastroenterology, hepatology, and nutrition at the University of Florida in Gainesville. “I feel like there's got to be something better—we just haven't discovered it.”

Instead, he suggested that physicians rely upon their clinical judgment, watching out for the presence of systemic inflammatory response syndrome along with other risk factors. “It's not really rocket science,” he said. “The older they are, the higher their risk. The more severe medical problems they have, the higher their risk. Obesity is a significant risk factor.”

But Dr. Haddad, who wrote a letter to the editor in response to the NEJM review, said that these scoring systems should not be so quickly dismissed. “It forces the clinician to consider the potential for complications or mortality,” he said.

Not all doctors have extensive experience with acute pancreatitis, and a delay in identifying those who might progress loses valuable time to intervene, Dr. Haddad said. For example, a patient admitted overnight might not receive sufficient resuscitation until a more senior doctor does rounds the next morning. “And then you're behind the eight ball,” he said.

Any scoring system should be only part of the diagnostic equation, along with a physician's judgment, Dr. Haddad said. He typically recommends to residents that they calculate risk using both HAPS (Harmless Acute Pancreatitis Score) and BISAP (Bedside Index for Severity in Acute Pancreatitis). Both systems are straightforward and rely on clinical markers that should have already been collected by ED clinicians, he said.

The strength of BISAP is that it indicates a patient's relative mortality risk, Dr. Haddad said. HAPS can potentially be used to ease concerns about potential severity. If all of the diagnostic components are absent, there's a high likelihood the patient will not progress to severe disease, he said.

But another review, this one for hospitalists published in the Oct. 11, 2016, Journal of Hospital Medicine (JHM), steers doctors away from relying on scoring systems. Instead hospitalists should focus on laboratory results that indicate inflammation, such as elevations in blood urea nitrogen (BUN) and hematocrit, or values in liver tests and creatinine that indicate organ damage, the authors said.

Given that gallstones are the most common cause of acute pancreatitis, implicated in roughly half of cases, according to the JHM review, an ultrasound should be part of a patient's early diagnostic workup. But a physician shouldn't order a CT scan initially as part of a diagnostic workup for pancreatitis and, in fact, the scan could be misleading early on, said Timothy Gardner, MD, associate professor of medicine at Geisel School of Medicine at Dartmouth in Hanover, N.H., and a coauthor on the JHM review.

It's best to defer getting the image for at least 48 to 72 hours, he said. It takes a while for things to develop, if there is going to be a complication,” such as necrosis, he said.

Managing care

A primary reason to identify vulnerable patients shortly after they arrive at the hospital is so they can be transferred to a higher level of care with closer monitoring, experts said.

Those measures don't “really keep it from becoming severe,” said Dr. Forsmark. “It just lets you identify problems as they are developing and hopefully manage them as best you can.”

Once patients are transferred to a higher-acuity unit, aggressive fluid resuscitation can be provided. The earlier that those fluids—typically lactated Ringer's solution—are started, the better for the patient, said Amindra Arora, MB, BChir, a professor of medicine and a consultant in gastroenterology and hepatology at the Mayo Clinic in Rochester, Minn.

“You only have about 12 to 24 hours,” he said. “After that the fluid resuscitation doesn't really make much difference. The die is cast by then,” he said, in terms of organ damage and necrosis.

It can be challenging to determine precisely how much fluid to give, said Dr. Forsmark, who cautions that doctors should keep a close eye on how much their patient can tolerate. If the patient is older or has other health conditions, such as lung or kidney problems, too much fluid can be potentially harmful, he said.

Until the symptoms resolve, pain control is essential, although no studies have identified the optimal narcotic to use, the JHM review article said. Prophylactic antibiotics should be avoided unless there is a clear sign of infection, the authors wrote.

And while the serum amylase and lipase levels are checked as part of diagnosis, the bloodwork doesn't need to be repeated later, Dr. Gardner said. Sometimes clinicians will continue to monitor those readings and base their management on whether they're going up or down, he said. “But they really don't have any prognostic value.”

If the patient isn't improving after three to five days—for example, if he or she is still having pain and is unable to take anything by mouth—then it is time to order a CT scan, Dr. Arora said.

If gallstones are implicated, the gallbladder should ideally be removed during that initial hospitalization, Dr. Forsmark said. He cited a study, published Sept. 26, 2015, in The Lancet, finding that patients whose gallbladders were removed before they went home had a far lower chance of recurrent gallstone-related complications. In the six months after hospitalization, only 5% of patients who underwent immediate surgery were readmitted for a related reason or died versus 17% of those whose operation was postponed until after discharge.

Sometimes a delayed operation makes sense, such as when a patient is still recovering from necrosis, Dr. Arora said. Otherwise, he said, “They should not be dismissed with their gallbladder intact.”