Medical Care: The medical management of mild acute pancreatitis is relatively straightforward. The patient is kept NPO (non per os, ie, nothing by mouth), and intravenous fluid hydration is provided. Analgesics are administered for pain relief. Antibiotics are generally not indicated. If ultrasonograms show evidence of gallstones and if the cause of pancreatitis is believed to be biliary, a cholecystectomy should be performed during the same hospital admission. Feeding should be introduced enterally as the patient's anorexia and pain resolves.
In contrast, patients with severe acute pancreatitis require intensive care. Within hours to days, a number of complications (eg, shock, pulmonary failure, renal failure, gastrointestinal bleeding, multiorgan system failure) may develop. The goals of medical management are to provide aggressive supportive care, decrease inflammation, limit infection or superinfection, and identify and treat complications as appropriate.
" Fluids: Patients are kept NPO and require intravenous hydration. Especially in the early phase of the illness, aggressive fluid resuscitation is critically important. This cannot be overemphasized. There is no universal consensus showing a definitive advantage of one type of fluid over another type. Resuscitation should be enough to maintain hemodynamic stability, which is usually an initial several liter fluid bolus followed by 250-500 cc/h continuous infusion. Careful attention should be paid to signs of overhydration, such as pulmonary edema causing hypoxia.
" Antibiotics
o Antibiotics, usually drugs of the imipenem class, should be used in any case of pancreatitis complicated by infected pancreatic necrosis. They should not be given routinely for fevers, especially early in the disease course, as this symptom is almost universally secondary to the inflammatory response and not an infectious process.
o Several controlled trials have evaluated the role of empiric antibiotics in patients with severe acute necrotizing pancreatitis for infectious prophylaxis. Antibiotics should not be used as prophylaxis in patients with mild pancreatitis.
o One such trial evaluated the role of imipenem/cilastatin initiated at admission to prevent infected pancreatic necrosis. This drug combination penetrates the pancreatic parenchyma and reduces the risk of intra-abdominal infection. This showed some benefit in preventing infectious complications. Unfortunately, fungal superinfection tends to develop later in the clinical course, although this risk is probably overinflated.
o A randomized trial failed to show any benefit of ciprofloxacin and metronidazole in preventing infectious complications, and thus this drug combination is not routinely used for prophylaxis in this disease.
o The bottom line is that antibiotic prophylaxis in severe pancreatitis is controversial. If one does decide to use antibiotic prophylaxis in patients admitted with severe acute pancreatitis, they should be placed on drugs of the imipenem class.
" ERCP: If the imaging and laboratory study findings are consistent with severe acute gallstone pancreatitis that is not responding to supportive therapy or with ascending cholangitis with worsening signs and symptoms of obstruction, early ERCP with sphincterotomy and stone extraction is indicated.
" Nutrition
o Early initiation of enteral nutritional supplementation and maintenance of a positive nitrogen balance is important in patients with severe pancreatitis.
o Theoretical considerations regarding the ability of the enterocyte to maintain a barrier against bacterial translocation favor nasojejunal feedings. Thus, in all patients admitted to the ICU, nasojejunal feedings should be attempted beginning at admission. For patients with mild acute pancreatitis, nasojejunal feedings can be avoided unless patients are unable to tolerate oral intake for over 1 week.
o Depending on the situation, TPN, which has been shown to reduce mortality rates, may be necessary. However, TPN should generally be reserved as a second-line therapy behind enteral feeding.
" Emerging treatments
o Although the role cytokines play in systemic inflammatory response syndrome appears important, a recent large clinical trial of lexipafant, a platelet-activating factor antagonist, has shown no benefit in patients with severe acute pancreatitis.
o Because multiple pathways are involved in the inflammatory response, further research is needed in order to define which cytokine or combination of cytokines should be targeted to ameliorate the complications of acute pancreatitis.
" Clinical vigilance
o In the following weeks (to months) after presentation, the physician's attention shifts to developing signs of intra-abdominal infection, pancreatic pseudocyst, intra-abdominal hemorrhage, colon perforation, obstruction or fistulization, and multiorgan system failure.
o The clinician cannot rely on clinical grounds alone to differentiate infected and sterile pancreatic necrosis. When clinical signs of infection or a systemic inflammatory response is present in the setting of necrotizing pancreatitis, CT-guided needle aspiration is indicated.
Surgical Care: Surgical intervention, whether by minimally invasive or conventional open techniques, is indicated when an anatomical complication amenable to a mechanical solution is present. Depending on the situation and local expertise, this may require the talents of an interventional radiologist, interventional endoscopist, and/or surgeon (alone or in combination).
" Pancreatic duct disruption: Damage to the pancreatic ductal system may allow pancreatic juice to leak from the gland. The sudden development of hypocalcemia or a rapid increase in retroperitoneal fluid on CT scan is suggestive of this condition.
o When imaging studies contain corroborating data, the condition is initially managed by percutaneous placement of a drainage tube into the fluid collection under the guidance of ultrasonography or CT scanning. Fluid amylase or lipase levels in the ten thousands strongly suggest the presence of a ductal disruption.
o In the appropriate clinical setting, endoscopic retrograde pancreatography confirms the diagnosis and provides a treatment option. Transpapillary stent placement or, preferably, placement of a 6F nasopancreatic tube attached to an external bulb suction device can successfully treat leaks by removing the sphincter tone and changing the dynamics of fluid flow in favor of ductal healing. Occasionally, leaks are associated with downstream stenoses that are also amenable to endoscopic treatment techniques.
o Refractory cases may require surgery. If the persistent leak is present in the tail of the gland, a distal pancreatectomy is preferred. If the leak is in the head of the gland, a Whipple procedure is the operation of choice.
" Pseudocysts: By definition, peripancreatic fluid collections persisting for more than 4 weeks are termed acute pseudocysts. Pseudocysts lack an epithelial layer and, thus, are not considered true cysts. In addition, the term cyst is also a misnomer, as most of these collections are filled with necrotic debris and not fluid. A more descriptive term for these collections may be organized necrosis. Most of these can be followed clinically. When pseudocysts are symptomatic (ie, associated with pain, bleeding, or infection) or are larger than 7 cm and are rapidly expanding in an acutely ill patient, intervention is indicated. The following therapeutic approaches may be implemented, depending on anatomical relationships and the duration of the natural history of the complication.
o Percutaneous aspiration: In selected patients with very large fluid collections, percutaneous aspiration of pancreatic pseudocysts is a reasonable approach. Even though treatment failures are common when the pseudocyst communicates with the pancreatic ductal system, percutaneous drainage serves as a temporizing measure that may later lead to successful endoscopic or surgical intervention. Often, an infected pseudocyst (which by definition is regarded as a pancreatic abscess) can be successfully managed by percutaneous drainage.
o Endoscopic techniques: Pseudocysts may be managed endoscopically by transpapillary or transmural techniques. Transpapillary drainage requires the main pancreatic duct to communicate with the pseudocyst cavity, ideally in the head or body of the gland. The proximal end of the stent is placed into the cyst cavity, and the stent should be smaller than the diameter of the pancreatic duct. The technical success rate is 83%, with a complication rate of 12%. Generally, however, pancreatic stents are difficult to monitor, prone to obstruction, and associated with an increased risk of infection and ductal injury.
o Some noncommunicating pseudocysts may be amenable to transmural enterocystostomy. Technical success requires a mature cyst that bulges into the foregut, and the distance from the lumen to the cyst cavity should be less than 1 cm. The success rate is 85%, with a complication rate of 17%. The transduodenal approach is associated with fewer complications and recurrences than the transgastric approach.
o Surgical cyst-enterostomy: Based on prospective data from the 1970s, surgery is recommended for persistent, large (>7 cm), pancreatic pseudocysts because complications developed in 41% of patients, 13% of whom died. Internal pseudocyst enteric anastomosis became the standard of care, with an operative mortality rate of 3-5%. Recently, this dogma has been challenged by 2 retrospective studies in which patients with smaller asymptomatic pseudocysts (ie, <5 cm) rarely developed complications (<10%).
" Infected pancreatic necrosis: Surgery is recommended when large areas of the pancreas are necrotic and percutaneous CT-guided aspiration demonstrates infection based on a positive Gram stain result. Antibiotic therapy alone is not sufficient to achieve a cure. Aggressive surgical debridement and drainage is necessary to remove dead tissue and to clear the infection.
" Pancreatic abscesses: Pancreatic abscesses generally occur late in the course of pancreatitis. Many of these respond to percutaneous catheter drainage and antibiotics. Those that do not respond require surgical debridement and drainage.
Consultations: The most effective and soundly based treatment plan for any disorder is one aimed at the mechanism responsible for the development of the disorder. With that axiom in mind, treatment of the patient must address the underlying cause of pancreatitis.
" Treatment of patients with alcohol-induced pancreatitis should go beyond the physical manifestations of this disease and address the underlying psychological addiction to alcohol. Simply telling patients they must stop drinking alcohol is not satisfactory. Successful treatment often requires the involvement and expertise of a chemical dependency counselor. The author favors in-hospital consultation with all patients admitted with alcoholic pancreatitis.
" Patients with hypertriglyceridemic- or hypercalcemic-induced pancreatitis require consultation with an endocrinologist. Rarely, such patients require surgical intervention for treatment of hyperparathyroidism or control of hyperlipidemia refractory to medical therapy.
" It is optimal for patients admitted with gallstone pancreatitis to have a cholecystectomy prior to discharge and not, for example, scheduled for a later date as an outpatient. Patients discharged with gallstone pancreatitis without a cholecystectomy are at high risk for recurrent bouts of pancreatitis.
" Patients with gallstones or microlithiasis revealed on imaging studies should have a surgical consultation for gallbladder removal. Because microlithiasis is the most common cause of idiopathic pancreatitis, a patient with recurrent idiopathic pancreatitis should undergo cholecystectomy before procedures associated with a higher risk of complications (eg, ERCP) are performed.
" Patients with medication-induced acute pancreatitis may benefit from clinical pharmacology consultation during their hospitalization to maximize their therapeutic regimen.
Diet: General guidelines for nutritional support of patients with acute pancreatitis include the following:
" In patients with mild uncomplicated pancreatitis, no benefit is observed from nutritional support, and the energy (caloric) intake received with intravenous dextrose 5% in water (D5W) suffices. Oral feedings should be initiated once the patient's pain and anorexia resolve.
" In patients with moderate-to-severe pancreatitis, begin nutritional support early in the course of management, as soon as stabilization of fluid and hemodynamic parameters permits. Optimally, nasojejunal feedings with a low-fat formulation should be initiated at admission. The success of nasogastric tube feedings has also recently been compared to nasojejunal feedings in one randomized study. The study showed equivalent outcomes for patients with severe pancreatitis fed with nasogastric feedings compared with nasojejunal feedings.
" However, TPN may be required in patients who are unable to maintain their caloric needs with enteral nutrition or because adequate jejunal access cannot be maintained. TPN should include fat emulsions in amounts sufficient to prevent essential fatty acid deficiency.
" If surgery is required for diagnosis or complications of the disease, place a feeding jejunostomy at the time of the operation. Use a low-fat formula.
" Begin oral feedings once abdominal pain has resolved and the patient regains appetite. The diet should be low in fat and protein. A recent prospective, randomized study showed that initiating feeding with a low-fat solid diet was as well tolerated as initiating feeding with a clear liquid diet, but it did not result in a shorter length of stay.
DRUG TREATMENT :
1. ANALGESICS :
- ACETAMINOPHEN
- ACETAMINOPHEN WITH PROPOXYPHENE
- TRAMADOL
- MEPERIDINE
2. ANTIBIOTICS :
- IMIPENEM & CILASTATIN OR ANY OTHER UNIVERSALLY SAFE ANTIBIOTIC