Outline the diagnostic features, complications and treatment of critically ill patients with pancreatitis.
This is a complex field with a large amount of literature to collate. Pancreatitis is usually presents with persistent upper abdominal pain, associated with nausea and vomiting, which can be associated with signs of local tenderness through to peritonism, and/or signs of a systemic inflammatory response (e.g. fever, tachycardia) or signs of associated disorders (e.g. jaundice with biliary obstruction) or rarely signs of complications (e.g. ecchymotic discoloration in flank [Grey-Turner’s sign] or peri-umbilical [Cullen’s sign] regions). These signs may be difficult to elicit or masked in critically ill patients. Investigations that assist in the diagnosis include: serum amylase (usually > 3 times normal) (serum lipase does not improve diagnostic accuracy); liver function tests (looking for evidence of obstructive pattern with gall stone induced pancreatitis); plain abdominal radiograph (excludes other aetiologies, and may show localised ileus [“sentinel loop”]; abdominal ultrasound (enlarged hypo-echoic pancreas, and looking for gall stones); and abdominal CT scan with contrast (confirm diagnois and looking for areas of necrosis or pseudocysts). Ranson’s criteria (or more recently Glasgow criteria or Imrie score) are used to assess severity and predict outcome, and they include white cell count (>16,000/mm3), glucose (>11 mmol/L), AST > 250 IU/L, Ca < 2mmol/L, hypoxaemia (<8kPa), and a decrease in haematocrit (>10%) and an increase in urea (>1.8 mmol/L).
Complications include: those associated with a systemic inflammatory response (e.g. myocardial depression/shock, ARDS, renal failure, death); respiratory (including pleural effucsion and atelectasis); metabolic (including hypocalcaemia, glucose disturbances); and intrabdominal problems (including ileus, necrosis, pseudo-cysts, abscess formation, etc).
Treatment should include: aggressive fluid resuscitation to stabilise the haemodynamic state, treatment of underlying cause (e.g. ERCP if gall stones present, withdrawal of offending drug), treatment of pain (morphine controversial), surgical treatment of complications (e.g. aspiration/drainage of infected collections) and general support of the critically ill patient. More contentious issues that should be considered include: early prophylactic broad spectrum antibiotics (evidence that decrease complications), prophylactic anti-fungal therapy, jejunal feeding (safe, feasible, cheaper than TPN, possibly of benefit), the use of somatostatin, octreotide or protease inhibitors (none have sufficient evidence base to use routinely), and the timing and nature of surgical interventions.
This question dates back to a time when there was a whole massive period during which one had plenty of thinking room, planning, and then the process of written communication could take place at a civilised pace, without rush. Now, of course, a question like this has the candidate trying to fit the last 30 years of pancreatitis literature into a ten minute answer.
One patently cannot do this.
The suggested answer below is one which could easily be produced over the course of ten minutes.
Wilmer, Alexander. "ICU management of severe acute pancreatitis." European journal of internal medicine 15.5 (2004): 274-280.