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Pancreatitis

Etiology

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Clinical Presentation

• Pain: Epigastric, often radiating to the back; constant, boring in character; worsens supine, may improve leaning forward
• Nausea and vomiting: Almost universal
• Fever and tachycardia: Common in moderate-severe disease
• Grey Turner's sign (flank ecchymosis) and Cullen's sign (periumbilical ecchymosis): Rare but indicate hemorrhagic pancreatitis

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Diagnosis

• Serum amylase >3× ULN or serum lipase >3× ULN (lipase is more sensitive and specific)
• Elevated WBC, CRP, LDH, bilirubin (if biliary cause)
• Elevated creatinine (if AKI develops)

• Ultrasound (US): First-line to identify gallstones and biliary dilation
• CT abdomen (contrast-enhanced): Gold standard for severity assessment; best performed 48–72 hours after symptom onset if diagnosis is unclear or severity is in question

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CT Imaging: Necrotizing Pancreatitis

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Severity Classification (Revised Atlanta 2013)

• Ranson criteria: Scored at admission + 48 h; ≥3 = severe
• Glasgow (Imrie) score: ≥3 at 48 h = severe
• APACHE II: Can be applied throughout admission
• CRP >150 mg/L at 48 h: Independent severity marker
• BMI >30: Higher risk of complications

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Management

Mild Pancreatitis

1. IV fluid resuscitation: Lactated Ringer's preferred over NS (reduces SIRS); 250–500 mL/hr initially
2. NPO initially, then early oral feeding as tolerated (within 24–48 h if possible)
3. Analgesia: IV opioids (morphine, hydromorphone); multimodal approaches preferred
4. Monitoring: Vitals, urine output, labs (BMP, CBC)

Moderate-Severe / Severe Pancreatitis

1. ICU-level care if persistent organ failure
2. Aggressive fluid resuscitation with close monitoring
3. Enteral nutrition (nasojejunal feeding) preferred over TPN; start within 24–72 h
4. ERCP: Urgent (<24–72 h) if cholangitis or persistent biliary obstruction
5. Antibiotics: NOT prophylactic; only indicated for confirmed infected necrosis
6. Surgical/interventional: Step-up approach for infected or symptomatic necrosis — percutaneous drainage → endoscopic/surgical debridement (necrosectomy)

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Local Complications

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Systemic Complications

• ARDS (most common cause of early death)
• AKI
• DIC
• Hypocalcemia (saponification of fat)
• Hyperglycemia
• Pleural effusions

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Chronic Pancreatitis

• Triad: Chronic epigastric pain, steatorrhea, diabetes mellitus
• Imaging: Pancreatic calcifications (pathognomonic), dilated main pancreatic duct
• Management: Pain control (stepwise), pancreatic enzyme replacement therapy (PERT), treat diabetes, alcohol/smoking cessation, endoscopic or surgical decompression in selected cases

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• Lipase is the preferred diagnostic enzyme
• Revised Atlanta 2013 guides severity stratification
• Most cases are mild and self-limiting; aggressive early fluids are the cornerstone of treatment
• Antibiotics are not routine; reserve for proven infected necrosis
• Early enteral nutrition is superior to TPN in severe disease

Critical Illness Summary

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ABG Interpretation

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Differentials for Fever + Respiratory Failure in This Context

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Criteria for Severe Malaria (this patient meets multiple):

• ✅ Respiratory distress / ARDS
• ✅ Circulatory collapse (on norepinephrine)
• ✅ Impaired consciousness (assess GCS)
• Hyperparasitemia (>5%) — check smear urgently
• Hypoglycemia — monitor closely (glucose 207 currently, but can drop rapidly with artesunate + quinine)
• Renal failure — check creatinine
• Jaundice — check bilirubin
• Abnormal bleeding — check PT/aPTT

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Investigations — Urgent

Immediate (Stat)

Within 12–24 Hours

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Treatment Plan

1. Anti-malarial (Priority 1)

• Dose: 2.4 mg/kg IV at 0, 12, 24 hours, then once daily until oral therapy possible
• Transition to oral Artemisinin-based Combination Therapy (ACT) once tolerating orals:
  • Artemether-Lumefantrine (Coartem) OR
  • Artesunate + Mefloquine / Doxycycline
• Monitor glucose Q2H — artesunate-associated delayed hemolysis can occur; watch Hb from day 7–28
• Avoid quinine if possible (QTc prolongation risk in post-PTCA patient)

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2. Respiratory Management

• NIV settings: IPAP 12–16 cmH₂O, EPAP 8–10 cmH₂O, FiO₂ titrate to SpO₂
• Reassess in 1–2 hours — if no improvement (SpO₂ <90%, RR unchanged, worsening sensorium) → early intubation with lung-protective ventilation
  • Tidal volume 6 mL/kg IBW
  • PEEP 8–12 cmH₂O (titrate via P-V tool or empiric)
  • Plateau pressure <30 cmH₂O
• Prone positioning if PaO₂/FiO₂ <150 despite optimization
• Caution with fluids: EF 40% + ARDS = high risk of flash pulmonary edema; target conservative fluid strategy guided by BNP + ECHO

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3. Hemodynamic / Vasopressor Management

• Norepinephrine already running — titrate to MAP ≥65 mmHg (or ≥70 mmHg given EF 40%)
• If norad >0.25 mcg/kg/min → add Vasopressin 0.03 units/min (vasopressor-sparing, reduces norad dose)
• Dobutamine: Consider if low cardiac output state (post-PTCA, EF 40%, cold peripheries, high lactate) — start 2.5–5 mcg/kg/min
• Avoid volume loading — high risk of pulmonary edema in EF 40%
• Check ECHO urgently to differentiate:
  • Distributive shock (warm, low SVR) — malaria/sepsis
  • Cardiogenic component (cold, low CO) — EF 40% decompensation

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4. Fluid & Electrolyte Management

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5. Antibiotic Cover

• Start empiric broad-spectrum antibiotics given septic shock picture (cannot exclude bacterial co-infection):
  • Piperacillin-Tazobactam 4.5g IV Q6H (or Meropenem if high ESBL risk)
  • +/- Azithromycin (covers atypicals, also has anti-malarial properties)
• De-escalate based on cultures at 48–72 hours

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6. Cardiac Monitoring & Protection

• Continuous ECG monitoring (QTc — especially relevant for any anti-malarial)
• Avoid QTc-prolonging drugs wherever possible
• Statin continuation (if on one for post-PTCA)
• Hold ACE inhibitor / ARB if hypotensive
• Aspirin: Continue if on it post-PTCA, assess bleeding risk vs. thrombotic risk
• Beta-blocker: Hold or reduce if hemodynamically unstable / HR 150 with shock; re-evaluate once stable
• HR 150 — rule out AF with RVR (common in sepsis + malaria): 12-lead ECG urgently; if AF → rate control cautiously (amiodarone preferred in low EF)

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7. Additional Supportive Care

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Red Flags to Watch — Deterioration Triggers

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Summary of Immediate Priorities

1. IV Artesunate — start immediately (do not delay for investigations)
2. Peripheral smear — confirm parasitemia %
3. Serum lactate + cultures + CBC — stat
4. NIV optimization — reassess in 1–2 hrs; low threshold to intubate
5. Bedside ECHO — differentiate distributive vs. cardiogenic shock
6. Broad-spectrum antibiotics — empiric cover
7. 12-lead ECG — rule out AF, QTc monitoring
8. Strict glycemic control and I/O monitoring