gastrointestinal disorders
Acute Pancreatitis
Treatment of Acute Pancreatitis
Supportive measures For severe acute pancreatitis and complications, antibiotics and therapeutic interventions as needed Treatment of acute pancreatitis is typically supportive. Patients who develop complications may require specific additional treatment. (See also the 2013 American College of Gastroenterology'sguidelines for the management of acute pancreatitis.) The basic treatment of acute pancreatitis includes Early goal-directed fluid resuscitation Analgesia Nutritional support The 2013 American College of Gastroenterology (ACG) guidelines recommend that early, aggressive fluid resuscitation, defined as 250 to 500 mL/hour of isotonic crystalloid solution (ideally lactated Ringer's solution), be provided to all patients during the first 12 to 24 hours unless contraindicated by cardiovascular, renal, or other related comorbid factors. Adequacy of fluid replacement can be assessed by reduction in hematocrit and bloodureanitrogen levels over the first 24 hours, particularly if they were high at the onset. Other parameters include improvement in vital signs and maintenance of adequate urine output. The ACG guidelines also recommend that fluid requirements be reassessed at frequent intervals in the first 6 hours of admission and for the next 24 to 48 hours. Patients undergoing volume resuscitation should have pulse oximetry monitored continuously, receive supplemental oxygen as needed, and have their fluid intake and output strictly monitored. Adequate pain relief requires use of parenteral opioids such ashydromorphoneorfentanyl, which should be given in adequate doses. Becausemorphinecan theoretically increase pressure in the sphincter of Oddi,hydromorphoneis usually preferred tomorphine. Antiemetic drugs should be given to relieve nausea and vomiting. Early enteral nutrition is recommended because it is associated with lower morbidity compared to delayed or no nutrition. Patients with mild pancreatitis can begin an oral low-residue, low-fat, soft diet as soon as it can be tolerated. If oral nutrition cannot be initiated early in the disease course, enteral feeding is preferred over total parenteral nutrition because parenteral nutrition is associated with increased risk of infectious complications and organ failure. Treatment of severe acute pancreatitis and complications includes Intensive care unit (ICU) care Enteral nutrition preferred over parenteral nutrition Antibiotics for extrapancreatic infections and infected necrosis Necrosectomy (removal of necrotic tissue) for infected necrosis Endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis and concurrent acute cholangitis Drainage of pseudocysts The management of patients with severe acute pancreatitis and its complications should be individualized using a multidisciplinary approach including therapeutic endoscopists, interventional radiologists, and a surgeon. Patients with severe acute pancreatitis should be monitored closely in the first 24 to 48 hours in an ICU. Patients with worsening condition or widespread local complications requiring intervention should be transferred to centers of excellence focusing on pancreatic disease (if available). Patients with severe acute pancreatitis may need artificial nutritional support, although the optimal starting time and duration of nutritional support are still unclear. The 2013 American College of Gastroenterology (ACG) guidelines recommend using enteral nutrition and giving parenteral nutrition only if the enteral route is not available, not tolerated, or not meeting caloric requirements. The enteral route is preferred because it Helps maintain the intestinal mucosal barrier Prevents the intestinal atrophy that can occur with prolonged bowel rest (and helps prevent translocation of bacteria that can seed pancreatic necrosis) Avoids the risk of infection of a central IV catheter Is less expensive A nasojejunal feeding tube placed beyond the ligament of Treitz may help avoid stimulating the gastric phase of the digestive process; placement requires radiologic or endoscopic guidance. If a nasojejunal feeding tube cannot be placed, nasogastric feeding should be initiated. In both cases, patients should be placed in the upright position to decrease risk of aspiration. The ACG guidelines note that nasogastric and nasojejunal feeding appear comparable in their efficacy and safety. According to the 2013 ACG guidelines and the 2018 American Gastroenterological Associationguideline on initial management of acute pancreatitis, prophylactic antibiotics are not recommended in patients with acute pancreatitis, regardless of the type or disease severity. However, antibiotics should be started if patients develop an extrapancreatic infection (eg, cholangitis, pneumonia, bloodstream infection, urinary tract infection) or infected pancreatic necrosis. Infection (pancreatic or extrapancreatic) should be suspected in patients who have signs of deterioration (eg, fever, hypotension, tachycardia, altered mental status, increasing white blood cell count) or who fail to improve after 7 to 10 days of hospitalization. Most infections in pancreatic necrosis are caused by single bacterial species from the gut. The most common organisms are gram-negative bacteria; gram-positive bacteria and fungi are rare. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, fluoroquinolones, andmetronidazole, are recommended. For necrosectomy (removal of infected tissue), a minimally invasive approach is preferred over an open surgical approach and should be attempted initially. The 2013 ACGguidelinesrecommend that drainage of infected necrosis (radiologic, endoscopic, or surgical approach) should be delayed, preferably for > 4 weeks in stable patients, to allow liquefication of the contents and the development of a fibrous capsule around the necrosis (walled-off necrosis). More than 80% of patients with gallstone pancreatitis pass the stone spontaneously and do not require endoscopic retrograde cholangiopancreatography (ERCP). Patients with acute pancreatitis and concurrent acute cholangitis should undergo early ERCP. Patients with mild gallstone pancreatitis who spontaneously improve should undergo cholecystectomy before discharge to prevent recurrent attacks. A pseudocyst that is expanding rapidly, infected, bleeding, or likely to rupture requires drainage. Whether drainage is percutaneous, surgical, or endoscopic ultrasound–guided cystogastrostomy depends on location of the pseudocyst and institutional expertise. 