Pancreatitis Diagnosis for New Nurse Practitioners
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Show notes:
Epigastric pain as a chief complaint happens ALL the time in primary care.
And we all order labs to help rule out pancreatitis, but most clinicians feel uncomfortable with diagnosing pancreatitis in primary care.
Even though it’s not that common, it’s certainly a red flag diagnosis to watch out for.
Diagnosing Pancreatitis in Primary Care
In this video I cover:
The main causes of pancreatitis
What labs to order and what to look out for
Criteria for diagnosing pancreatitis
Next steps to take when you suspect it
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well hey there it's liz for more from
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real world np and you're watching np
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patients
Overview
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so this week i'm going to be talking
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about pancreatitis the general
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approach to diagnosis as well as the
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clinical presentation and kind of the
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steps to take from there including some
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lab interpretation
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so um to start and i have my notes here
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to the side so i'm not miss speaking at
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all
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to start there's three main causes for
Causes
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pancreatitis so um gallstone
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pancreatitis
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and the pathophysis behind that is that
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there can be the thought is that a bile
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a stone
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is getting stuck in that area and
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there's a backsplash of bile into the
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towards the pancreas another one is
Alcohol
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chronic alcohol use and we don't really
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know what the pathophysiology
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behind that is it's not necessarily that
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someone has a copious amount of alcohol
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and that triggers pancreatitis it sounds
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like it can happen just any all time
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and full disclosure i've actually only
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seen historical pancreatitis in primary
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care not a patient in front of me it is
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not that common
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but i think it's important to talk about
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because unless we have that full
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understanding we won't necessarily know
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what we're looking for right
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especially with patients who come in
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with epigastric pain which is the main
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symptom which comes in literally all the
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time to primary care
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and we always order the labs for it so
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let's let's make sure that we know about
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it
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um but anyway so about half of patients
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will have radiating pain to the back
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it's usually a an abrupt onset like
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within days
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um and the gallstone pancreatitis tends
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to be an even more abrupt more localized
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uh reaction in the right upper quadrant
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with an onset of really rapid severe
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pain in 10 to 20 minutes
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again thought to be related to a moving
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stone of some kind
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and then the chronic alcohol related um
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pancreatitis is more like a diffused
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like poor less
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less well localized but still a an acute
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onset but not necessarily
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as rapid and then the other main cause
Clinical Presentation
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that i didn't mention yet is from high
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triglycerides and so those are the top
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three causes
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but alcohol and gallstones are the 75
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percent of all of the cases
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so the clinical presentation is again a
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an acute or rapid onset
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of epigastric pain half of people have
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it radiating to the back
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about 90 percent of people actually have
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nausea and vomiting that lasts several
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hours
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um and then some people can have some
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dyspnea related to diaphragmatic
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irritation and then some people can have
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jaundice if there is a
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gallstone that is that there's a stone
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stuck in the bile duct so those are more
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severe cases to watch out for
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and before i go any further actually
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it's really important to point out that
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pancreatitis is not something you're
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going to mess around with that i do not
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recommend
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i have not seen it myself in real person
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real people in front of me currently
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having symptoms
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so i recommend any it's just not that
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common and it is really serious so i do
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recommend if you have suspicions of this
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to
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get your colleagues or supervisor
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involved again putting ego aside and
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just making sure that the
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patient safety is paramount but yeah in
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terms of the physical exam i mean it's
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it's
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typically pretty severe abdominal pain
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on palpation as well
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and you're always watching out for
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peritoneal signs right the guarding the
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rebound
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really severe pain with like barely
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barely touching their abdomen
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um and there's mild moderate and severe
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pancreatitis and like i said this is
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just not that common in primary care
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and so if i were to see this i would do
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my full assessment in my exam
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and my evaluation and then i would
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definitely get somebody else involved in
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terms of the mild moderate and severe
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cases i would definitely be running that
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by somebody
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some cases are very mild um and they
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resolve within three to five days with
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just
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pain control and you know adequate
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hydration
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and kind of easing off of food for the
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first 24 hours of their symptoms and
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then slowly introducing like a soft
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bland diet
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to tolerance as they're doing uh with
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their pain but then other people need to
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be hospitalized so the severe cases
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though tend to have
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fever tachypnea hypoxemia hypotension so
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like those are a little bit more clear
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appearing right i think one thing to
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keep in mind is that um some patients
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basically everybody with pancreatitis
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has inflammation that's about 85
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of people and then the other 15 i'm
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loving these numbers i'm a real numbers
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person but about 15
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of people will have necrotizing
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pancreatitis which can lead to a whole
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host of other complications
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and that usually is observed on imaging
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by day three
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but let me let me just stop there for a
Diagnosis
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second and we'll work our way backwards
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so how are we going to diagnose this
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right so
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um there's three main criteria one is
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labs the other is the
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kind of a clinical presentation and the
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third one is imaging
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and textbook says you only need two
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uh two out of three so if you have those
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classic signs and symptoms and the labs
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that are reflective of that
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you could diagnose it but again i would
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tread very lightly here and i would take
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a case by case and consider doing
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imaging depending on what's in front of
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you
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how long it's been but i want to talk
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about analysts and life pace because i
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feel like everybody orders amylase in my
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place but i don't know if everyone feels
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comfortable with it
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so and again i'm looking at my notes so
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i don't misspeak so amylase rises within
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six to 12 hours
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of acute onset the half-life is about 10
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hours
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and so the problem with amylase is that
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it's fairly sensitive and specific
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however because it has a short half-life
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if you see somebody unless
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you see something in the first 24 hours
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that's not that useful of a test
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i mean you can still order it for sure
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and use it in comparison but lipays if
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you have to pick one
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i recommend choosing light pace
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hopefully you can do both and you can
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kind of compare the values right
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but lipase rises within four to eight
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out four
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to eight hours after symptom onset and
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it peaks
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about 24 hours and it takes about eight
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to 14 days to return to normal whereas
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the amylase
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takes about three to five days to return
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back to normal so it's a lot riser
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faster of a rise as well as a fall so
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the light base is going to be
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more persistently elevated so you might
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catch it
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that way so the main way that we
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diagnose
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pancreatitis is it's greater than three
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times the upper limit of normal and i
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talk about this in the lab course but
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it's talking about the reference range
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that you have
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and that very top one of the top of the
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reference range three times that is
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is is considered to be a diagnostic
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criteria for
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pancreatitis so um other things that
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you may consider to order when it comes
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to epigastric pain and looking into
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what's causing what's going on here
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in addition to the amylase and lipase
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cbc with differential can be helpful in
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terms of
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an infectious process however there can
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be reactive leukocytosis meaning the
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white blood cell count can go high
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just because of the reactive
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inflammation that's going on you can
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also have hemo concentration
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meaning that your hematocrit and
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hemoglobin will go high because of the
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fluid losses that can happen in terms of
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the pathophys
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behind pancreatitis and then you also
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want to consider
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and i mean i definitely would do lfds
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liver function test because again you're
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trying to see is this where is this
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coming from right is this a gallstone
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bigger titis
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what is the history kind of like like um
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suggestive of
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what is the alcohol intake like what is
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their triglycerides like right
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so doing lipids doing lfts making sure
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it has ast alt bilirubin calcium
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albumin things like that so um hopefully
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all of those things all together can be
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helpful but really the criteria is
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amylase and lipase
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and so if you have classic symptoms with
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those labs and you can get them back in
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the same day and they're not having a
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severe presentation
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that is diagnostic criteria enough
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versus if they seem unstable in any way
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getting somebody else involved and
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deciding whether or not they need to go
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to the er
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so yeah so that's the general gist of um
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diagnosing pancreatitis when it comes to
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imaging
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um usually if people are going to get
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worse and pancreatitis
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they're going to get worse in the first
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three or more like the first 72 hours of
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their symptoms
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you really want to make sure that
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they're not having any symptom decline
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so again in collaboration with a call
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with a supervisor having a conversation
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of like is this acceptable especially if
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it's a
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very slightly elevated emily sunlight
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pace it was very clear that it was
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some sort of like passage of a gallstone
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and they're not
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you know jaundice i mean it's it's all
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complicated so i would just kind of like
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leave it there
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and then kind of take it take it forward
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but typically just for informational
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purposes
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um they usually decline within the first
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72 hours because
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about 15 of people can have that
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necrotizing pinkertitis which can lead
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to the further severity which can lead
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to the complications
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and there's actually a five percent
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mortality rate so anyway
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um most people like i said do get better
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if it's mild they can be managed
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outpatient with a
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um with pain control adequate hydration
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and staying away from food in the first
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24 hours and then reintroducing a soft
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diet depending on how their pain is
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but i would not recommend doing that
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without anybody setting eyes on
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the plan of care because i would not do
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that myself so
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that is it that is the whole thing about
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pancreatitis so if you
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are struggling with labs if you love
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labs well if you love lips or you're
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struggling with labs
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you should definitely join us for the
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lab interpretation crash course
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we cover the main labs in primary care
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cbc cmp
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including those lfts and the cbc you
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ordered your analysis
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tsh lipids and the main endocrine labs
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in primary care and it's open all the
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time and there's also a facebook
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community that goes with it
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as well as live q as to review abnormal
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lab
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results so join us over at
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labs thank you so very much for watching
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let us know what questions you have and
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i will see you soon
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[Music]
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you
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