Pancreatitis medical therapy

Pancreatitis Main Page
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

Medical Therapy

The treatment of pancreatitis will, of course, depend on the severity of the pancreatitis itself. Still, general principles apply and include

• Provision of pain relief. In the past this was done preferentially with meperidine (Demerol), but it is now not thought to be superior to any narcotic analgesic. Indeed, given meperidine's generally poor analgesic charactersitics and its high potential for toxicity, it should not be used for the treatment of the pain of pancreatitis
• Provision of adequate replacement fluids and salts (intravenously),
• Limitation of oral intake (with dietary fat restriction the most important point), and
• Monitoring and assessment for, and treatment of, the various complications listed above.
• When necrotizing pancreatitis ensues and the patient shows signs of infection it is imperative to start antibiotics such as Imipenem due to its high penetration of the drug in the pancreas.

Acute Pancreatitis Treatment

• IV fluid replacement with careful monitoring urine output. Aggressive hydration at 250-500 ml/hr with Ringer's lactate in first 12-24 hrs. Reassess within 6 hrs after admission and for next 24-48 hrs
• Monitor serum electrolytes, calcium and glucose and supplement if needed.
• Nothing by mouth till pain subsides or else TPN or enteral feeds.Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside .
• Start with acid suppressing drugs to prevent from stress ulcers.
• Start with Narcotics for pain relief. Hydromorphone hydrochloride (dilaudid) is commonly used but meperidine is a very good alternative.

Chronic Pancreatitis Treatment

• Narcotic analgesics are seldom needed for pain control.
• Neuromodulators like TCA's and SSRI's and pregabalin may help in pain relief and decrease in opioid dependence.
• Pancreatic enzyme supplements can be started with a low fat diet <50 gm fat per day.
• Fat soluble vitamins should be supplemented.
• Insulin may be started for the diabetes cause by endocrine insufficiency.

Grading of Acute Pancreatitis

The definitions of severity in acute pancreatitis according to the revised Atlanta classification is as follows.

Interstitial edematous acute pancreatitis

There is edema of the pancreas following a bout of acute pancreatitis. The inflammation is more prominent in the parenchyma and tissues surroundingthe pancreas. No frank sign of necrosis are seen.

Necrotizing acute pancreatitis

Edema along with necrosis in the parenchyma and tissue surrounding pancreas is seen

Pancreatitis is classified according to severity in the following way:

1.Mild acute pancreatitis

• No organ failure
• No local or systemic complications

2.Moderately severe acute pancreatitis

• Organ failure that resolves within 48 h (transient organ failure) and/or
• Local or systemic complications without persistent organ failure

3. Severe acute pancreatitis

• Persistent organ failure (>48 h)
• Single organ failure
• Multiple organ failure

Antibiotic therapy

As per the 2012 guidelines the treatment of pancreatitis is divided in to three groups based on the following criteria :

1. Pancreatitis without necrosis
2. Prophylactic treatment for necrotizing pancreatitis on CT scan
3. Infected pseudocyst or pancreatic abscess

Pancreatitis   ▸  Pancreatitis without necrosis   ▸  Necrotizing pancreatitis on CT scan   ▸  Infected pseudocyst or abscess Pancreatitis without necrosis ▸ No indication for an antimicrobial agent. Necrotizing pancreatitis on CT scan ≥ 30% necrosis of the pancreas on a CT scan with contrast ▸ Moxifloxacin 400 mg IV once daily ▸Imipenem 0.5-1 gm IV q6h OR ▸Meropenem 1 gm IV q8h Treat for 14 days maximum

Infected pseudocyst or pancreatic abscess While awaiting culture result ▸ Piperacillin tazobactam 3.375 gm IV q6h OR ▸Moxifloxacin 400 mg IV once daily