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 amylase or lipase 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 organ failure persistent in >48 hours.

Principles of Therapy

  • 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 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
  • 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

Antibiotic Prophylaxis

  • 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
  • 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
    • 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
    • Cefuroxime, Ceftazidime, Imipenem have been used in studies
    • Combinations that have been studied include:
      • (Ciprofloxacin or Ofloxacin) + (Metronidazole or Clindamycin)
      • Amikacin + Ceftazidime + Metronidazole
      • (Cefotaxime or Ceftazidime) + (Metronidazole or Clindamycin)
  • If antibiotic prophylaxis is given, 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 antifungals given with antibiotics

Non-Pharmacological Therapy

  • 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 48 hours after admission
    • Enteral nutrition 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 nasojejunal or nasogastric tube
    • Low-fat, high protein preparations may be preferred
  • Parenteral nutrition should be used in patients who cannot tolerate enteral feeding or used as supplement in those whose nutritional goals are not met within 2 days
  • Oral feedings are resumed when abdominal pain and tenderness subside
    • In patients with mild pancreatitis, food intake is usually resumed within 3-7 days
      • Patients may be allowed to self-transition from NPO to regular diet 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
    • It is recommended that feedings should contain >50% carbohydrate with gradual increments in caloric content
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