pancreatitis%20-%20acute
PANCREATITIS - ACUTE
Acute pancreatitis is inflammation of the pancreas that occurs suddenly.
Abdominal pain is the most prominent symptom of acute pancreatitis.
It is diagnosed by at least two of the following: Characteristic abdominal pain, serum lipase and/or amylase levels ≥3 times the upper limit of normal and characteristic abdominal imaging findings.
Mild acute pancreatitis does not have any organ failure or local or systemic complication.
Moderately severe acute pancreatitis has the presence of local or systemic complication and/or transient organ failure in <48 hours.
Severe acute pancreatitis has single or multiple organ failure persistent in >48 hours.

Pancreatitis%20-%20acute Treatment

Clinical Decision

  • Consider performing interventions (eg percutaneous or endoscopic drainage) for pancreatic necrosis if 4 weeks after disease onset patient has ongoing organ failure with no sign of infected necrosis, ongoing gastric outlet, biliary or intestinal obstruction from a walled-off necrotic collection, disconnected duct syndrome, or growing or symptomatic pseudocyst; or ongoing discomfort and/or pain 8 weeks after disease onset  
    • Usually done 4 weeks after disease onset to allow for the necrosis to be walled off  
  • All patients with persistent symptoms and >30% pancreatic necrosis or those who have clinical suspicion of sepsis should have CT-guided fine-needle aspiration (FNA) to obtain sample for Gram stain and culture 7-14 days after the onset of pancreatitis

Pharmacotherapy

Pain Relief

  • Pain relief may be achieved with Pethidine (Meperidine), given at 50-100 mg IV 3-4 hourly
  • For severe pain, Hydromorphone may be administered using a patient-controlled anesthesia pump
    • Hydromorphone has a longer half-life than Pethidine and is preferred over Fentanyl or Morphine in a non-intubated patient in most institutions  
  • For patients with severe pancreatitis requiring high-dose opioids for an extended period of time, epidural analgesia may be considered
  • Some experts suggest avoiding the use of Morphine for pain relief
    • There is no conclusive study in humans to support the theory that Morphine and its derivatives may worsen pancreatitis by inducing an increased sphincter of Oddi tone
  • Anticholinergic agents eg Atropine should be avoided because these may aggravate ileus
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) should not be given in patients with acute kidney injury

Antibiotic Treatment

  • Treatment with antibiotics is recommended for patients with infected acute pancreatitis; however, routine antibiotic prophylaxis is not recommended for all patients with acute pancreatitis as evidences have not shown a significant reduction in morbidity or mortality with its use 
  • Bacterial infection of the pancreas and peripancreatic tissues arises in about 1/3 of patients with severe acute pancreatitis
    • Infection is usually seen later in the course of disease, especially if there is massive pancreatic necrosis
    • A serum procalcitonin level may be of use in predicting the possibility of an infected pancreatic necrosis; a CT-guided FNA (not routinely used) can confirm an infected severe acute pancreatitis and can guide antibiotic therapy from Gram stain and culture
  • The most important etiologic agents in necrotizing pancreatitis are part of the gut flora:
    • Gram-negative bacteria: Escherichia coli, Klebsiella sp; less commonly, Enterobacter sp, Pseudomonas sp, Proteus sp, etc
    • Gram-positive bacteria: Enterococcus sp, Streptococcus sp, Staphylococcus sp
    • Anaerobes
    • Occasional fungi: Candida sp 
    • The microbial flora in necrotizing pancreatitis is similar to that in colonic perforation
  • Some studies have shown that prophylactic antibiotics reduce mortality in severe acute pancreatitis; however, a universal recommendation regarding antibiotic prophylaxis is not yet available
  • Antibiotics that exhibit adequate penetration into the pancreas should be used
    • Third-generation cephalosporins and acylureidopenicillins are effective against Gram-negative bacteria
    • Piperacillin-tazobactam is effective against both anaerobes and Gram-positive bacteria
    • Metronidazole is effective against anaerobes
    • Carbapenems should only be used in patients who are critically ill due to the spread of carbapenem-resistant K pneumoniae
    • Quinolones should only be used in patients with beta-lactam allergy due to high rates of resistance
  • Antibiotics should be given for a maximum of 14 days in most cases
  • The following are not recommended regarding antibiotic usage:
    • Routine use of prophylactic antibiotics in severe acute pancreatitis
    • Using antibiotics to prevent an infected necrosis in patients with sterile necrosis
    • Routine use of prophylactic antifungals given with antibiotics

Non-Pharmacological Therapy

Nutritional Support

  • Patients with mild pancreatitis are advised to take nothing by mouth for the 1st few days, with hydration being carried out through the IV route
    • These patients usually tolerate oral feelings within 3-7 days of presentation
    • A solid diet of low fat is as safe as a diet of clear liquid
  • In patients requiring nutritional support especially those with severe pancreatitis, the enteral route should be used if it is tolerated and started within 24-72 hours after admission
    • Enteral nutrition1 preserves mucosal function and maintains the intestinal barrier, which reduces bacterial translocation from the gut
    • Less septic complications result from enteral nutrition as compared to parenteral nutrition
    • Enteral nutrition may be delivered using a nasogastric or nasojejunal tube; it is preferred to administer via a nasojejunal tube in patients with digestive intolerance or if indicated in patients who underwent minimally invasive necrosectomy
    • Low-fat, high-protein preparations may be preferred
  • Parenteral nutrition1 should be used in patients who cannot tolerate or has contraindications for enteral feeding, or used as supplement in those whose nutritional goals are not met within 2 days
    • Parenteral glutamine can be given to patients with severe acute pancreatitis
  • Oral feedings are resumed when abdominal pain and tenderness subside
    • In patients with mild pancreatitis, oral feeding should be restarted as soon as clinically tolerated with low-fat, soft oral diet
      • Patients may be allowed to transition from NPO to oral feeding within 24 hours as tolerated
    • In patients with severe pancreatitis, feedings may be started with liquids that do not contain calories, progressing gradually to soft then to solid foods
    • In patients who have undergone a minimally invasive necrosectomy, oral feeding should be started in the 1st 24 hours after the procedure if the patients’ condition allows it
    • It is recommended that feedings should contain >50% carbohydrate with gradual increments in caloric content
    • Oral pancreatic enzymes can be given as supplements to patients with obvious pancreatic exocrine insufficiency  

1Various enteral or parenteral nutritional products are available. Please see the latest MIMS for specific formulations and prescribing information 

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