Pancreatitis%20-%20acute Treatment

• 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

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

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