Pancreatitis medical therapy

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Pancreatitis Main Page

Patient Information

Overview

Causes

Classification

Acute Pancreatitis
Chronic Pancreatitis
Hereditary Pancreatitis
Autoimmune Pancreatitis

Differential Diagnosis

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

Overview

The management of pancreatitis depends on the severity and duration (acute vs. chronic) of the disease. Medical therapy for pancreatitis includes pain management, adequate fluid replacement, bowel rest, and monitoring and treatment of complications. Antimicrobial therapy is recommended for patients who develop necrotizing pancreatitis.

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.[1]Nasogastric or nasojejunal feeding may be initiated once pain, vomiting, nausea subside .
  • Start with acid suppressing drugs to prevent from stress ulcers.[2]
  • Start with Narcotics for pain relief. Hydromorphone hydrochloride (dilaudid) is commonly used but meperidine is a very good alternative.

Fluid replacement

  • Initiate with a fluid bolus
  • 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.[3][4]
  • Prevent the use of ringer lactate as some patient may have hypercalcemia and ringer lactate contains calcium though it reduces systemic inflammation as compared to saline. It has also shown that using ringer lactate reduces the risk of Systemic inflammatory response syndrome (SIRS) [5]
  • Fluid rate should be based on
    • Clinical evaluation
    • Hematocrit
    • Blood urea nitrogen (BUN)
  • The goal of fluid management should be evaluated by :[6]
    • Checking vital signs (HR <120 beats/ minute)
    • Urine output (>0.5 to 1 cc/kg/hour)
    • Hematocrit between 35-44 %
  • BUN should be monitered every 24 hrs as it is a very important sign to predict mortality.[7]
  • Aggressive treatment in the first few hours of presentation have shown to reduce mortality.[6][8][9][10]
  • A research study states that dehydration lasting more than 24 hours may lead to necrotizing pancreatitis.[11] Necrotizing pancreatitis leads to third space loss and in turn causes decreased circulation in the pancreas.[12]

Pain Management

  • Pain is mostly due to the ischemia and lactic acidosis due to intracellular dehydration.
  • Opioids are both safe and effective in treatment of pancreatitis.[13] An intravenous pump usually of hydromorphone or fentanyl is used.
  • Fentanyl has a very good safety profile compared to other opiods. It can be used in renal impaired patients. It can be administered as a infusion or one time bolus.
  • Meperidine is used widely as compared to morphine becasue morphine can cause spasm of the sphincter of Oddi.[14]

Hence it could worsen pancreatitis or cholecystitis. Meperidine has a short half life and hence caution should be taken in administering it otherwsie it may cause seizures.

Monitoring the patient in the ICU

  • Maintain oxygen saturation greater than 95 % at all times.
  • Hydrate the patient so that urine output should be between (>0.5 to 1 cc/kg/hour).
  • Correct hypocalcemia by checking for signs like Chvostek's or Trousseau's sign.
  • Suspect hypomagnesemia if hypocalcemia is not responding to treatment.
  • Check for glucose levels ever hour and suspect secondary pancreatitis or secondary infection if glucose greater than 180-200 mg/dl.
  • Check for abdominal compartment syndrome by regularly measuring pressure of the bladder.

Nutrition

Oral feeding
  • Oral feeds are needed to supplement nutrition and also provide hydration so that recovery occurs quick in mild pancreatitis. Moderate to severe pancreatitis patients need nasojejunal tube feeding for nutritional support.
  • Start with a low residue, low fat, soft diet till the patient doesn't complain of nausea and vomiting or signs of ileus in mild pancreatitis.[6]Start oral feeds as soon as pain decreases or inflammatory markers improve.
  • Early re-feeding may be safe even if the patient has symptoms of abdominal pain or enzymes have not been normalized.[15][16]
  • In severe pancreatitis parenteral feeding may be needed as the patient might not be able to tolerate oral feeds. Nausea, vomiting and inflammation of the gastrointestinal system make it difficult to initiate feeding.
Enteral feeding
  • Recommended only in moderate to severe pancreatitis where oral feeds cannot be taken by the patient.[17][18]
  • As soon as the patient is transferred to the ICU enteral feeding should be initiated. This decreases the complications of multi organ failure and systemic inflammatory response syndrome (SIRS).[19][20][21][22]
  • Nasojejunal tube are used primarily and secured using an endoscope beyond the ligament of Treitz.
  • Nasogastric should be started if nasojejunal tube cannot be secured. Nasogastric tube has similiar when compared to nasojejunal except that the risk of aspiration , pulmonary complications are high.[23][24][25][26]
  • Since pancreas cannot release enzymes efficiently diet rich in protein and low in fat should be supplemented with. Start with small feeds at a slower rate and then increase the feeds once they are tolerated. Any sign of bloating, diarrhoes, vomiting should be taken seriously and feeding should be withheld.
  • Since the gastro-intestinal system is not used due to pancreatitis enteral feeds help regulate the gut. They indirectly help in preventing complications

and decrease mortality.[27] [28][29][30]

Parenteral
  • Parenteral feeding should be started as soon as the patient stops tolerating oral feeds. It should be used only in indicated cases as it can prove to be harmful.[31][32]
  • A study revealed that enteral feeding alone had less mortality compared to combined enteral and parenteral feeding.[32]
  • A randomized study in ICU patients revealed that infections occurred less in patients who were started with parenteral feeding at a later date. These patients also required lesser ventilation. [33]
Treatment of Complications
  • A contrast-enhanced computed tomography (CECT) scan should be obtained in all patients graded as moderate to severe pancreatitis to evaluate the patients for infections or complications arising from the pancreas and around the pancreas.
  • The following table summarizes the complications of pancreatitis. There could be two types of complications :
  1. Local complications
  2. Systemic complications

Chronic Pancreatitis Treatment

  • Narcotic analgesics are seldom needed for pain control.
  • Neuromodulators like TCAs and SSRIs and pregabalin may help in pain relief and decrease in opioid dependence.[34]
  • 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.

Antibiotic therapy

  • One-fifth of pancreatitis patient develop infections around the pancreas. This intra-abdominal infection may also spread systemically and cause respiratory, urinary infections and other systemic complications. [35][36]
  • Start antibiotics as soon as source is identified. Antibiotics should be stopped if culture reveals no organism.
  • Prophylactic antibiotic have not been proved to be beneficial in patients of pancreatitis.[37]
  • A few fungii have been noted to complicate pancreatitis especially necrotizing pancreatitis. Appropriate antifungals should be started as soon as culture is positive for them.[38]

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

References

  1. ↑ Curtis, CS.; Kudsk, KA. (2007). "Nutrition support in pancreatitis". Surg Clin North Am. 87 (6): 1403–15, viii. doi:10.1016/j.suc.2007.08.010. PMID 18053838. Unknown parameter |month= ignored (help)
  2. ↑ "AGA Institute medical position statement on acute pancreatitis". Gastroenterology. 132 (5): 2019–21. 2007. doi:10.1053/j.gastro.2007.03.066. PMID 17484893. Unknown parameter |month= ignored (help)
  3. ↑ Gardner, TB.; Vege, SS.; Pearson, RK.; Chari, ST. (2008). "Fluid resuscitation in acute pancreatitis". Clin Gastroenterol Hepatol. 6 (10): 1070–6. doi:10.1016/j.cgh.2008.05.005. PMID 18619920. Unknown parameter |month= ignored (help)
  4. ↑ Haydock, MD.; Mittal, A.; Wilms, HR.; Phillips, A.; Petrov, MS.; Windsor, JA. (2013). "Fluid therapy in acute pancreatitis: anybody's guess". Ann Surg. 257 (2): 182–8. doi:10.1097/SLA.0b013e31827773ff. PMID 23207241. Unknown parameter |month= ignored (help)
  5. ↑ Wu, BU.; Hwang, JQ.; Gardner, TH.; Repas, K.; Delee, R.; Yu, S.; Smith, B.; Banks, PA.; Conwell, DL. (2011). "Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis". Clin Gastroenterol Hepatol. 9 (8): 710–717.e1. doi:10.1016/j.cgh.2011.04.026. PMID 21645639. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 6.2 Besselink, M.; van Santvoort, H.; Freeman, M.; Gardner, T.; Mayerle, J.; Vege, SS.; Werner, J.; Banks, P.; McKay, C. "IAP/APA evidence-based guidelines for the management of acute pancreatitis". Pancreatology. 13 (4 Suppl 2): e1–15. doi:10.1016/j.pan.2013.07.063. PMID 24054878.
  7. ↑ Wu, BU.; Johannes, RS.; Sun, X.; Conwell, DL.; Banks, PA. (2009). "Early changes in blood urea nitrogen predict mortality in acute pancreatitis". Gastroenterology. 137 (1): 129–35. doi:10.1053/j.gastro.2009.03.056. PMID 19344722. Unknown parameter |month= ignored (help)
  8. ↑ Talukdar, R.; Swaroop Vege, S. (2011). "Early management of severe acute pancreatitis". Curr Gastroenterol Rep. 13 (2): 123–30. doi:10.1007/s11894-010-0174-4. PMID 21243452. Unknown parameter |month= ignored (help)
  9. ↑ Trikudanathan, G.; Navaneethan, U.; Vege, SS. (2012). "Current controversies in fluid resuscitation in acute pancreatitis: a systematic review". Pancreas. 41 (6): 827–34. doi:10.1097/MPA.0b013e31824c1598. PMID 22781906. Unknown parameter |month= ignored (help)
  10. ↑ Gardner, TB.; Vege, SS.; Chari, ST.; Petersen, BT.; Topazian, MD.; Clain, JE.; Pearson, RK.; Levy, MJ.; Sarr, MG. (2009). "Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality". Pancreatology. 9 (6): 770–6. doi:10.1159/000210022. PMID 20110744.
  11. ↑ Brown, A.; Baillargeon, JD.; Hughes, MD.; Banks, PA. (2002). "Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis?". Pancreatology. 2 (2): 104–7. doi:10.1159/000055899. PMID 12123089.
  12. ↑ Whitcomb, DC.; Muddana, V.; Langmead, CJ.; Houghton, FD.; Guenther, A.; Eagon, PK.; Mayerle, J.; Aghdassi, AA.; Weiss, FU. (2010). "Angiopoietin-2, a regulator of vascular permeability in inflammation, is associated with persistent organ failure in patients with acute pancreatitis from the United States and Germany". Am J Gastroenterol. 105 (10): 2287–92. doi:10.1038/ajg.2010.183. PMID 20461065. Unknown parameter |month= ignored (help)
  13. ↑ Basurto Ona, X.; Rigau Comas, D.; Urrútia, G. (2013). "Opioids for acute pancreatitis pain". Cochrane Database Syst Rev. 7: CD009179. doi:10.1002/14651858.CD009179.pub2. PMID 23888429.
  14. ↑ Helm, JF.; Venu, RP.; Geenen, JE.; Hogan, WJ.; Dodds, WJ.; Toouli, J.; Arndorfer, RC. (1988). "Effects of morphine on the human sphincter of Oddi". Gut. 29 (10): 1402–7. PMID 3197985. Unknown parameter |month= ignored (help)
  15. ↑ Eckerwall, GE.; Tingstedt, BB.; Bergenzaun, PE.; Andersson, RG. (2007). "Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery--a randomized clinical study". Clin Nutr. 26 (6): 758–63. doi:10.1016/j.clnu.2007.04.007. PMID 17719703. Unknown parameter |month= ignored (help)
  16. ↑ Li, J.; Xue, GJ.; Liu, YL.; Javed, MA.; Zhao, XL.; Wan, MH.; Chen, GY.; Altaf, K.; Huang, W. (2013). "Early oral refeeding wisdom in patients with mild acute pancreatitis". Pancreas. 42 (1): 88–91. doi:10.1097/MPA.0b013e3182575fb5. PMID 22836861. Unknown parameter |month= ignored (help)
  17. ↑ Forsmark, CE.; Baillie, J. (2007). "AGA Institute technical review on acute pancreatitis". Gastroenterology. 132 (5): 2022–44. doi:10.1053/j.gastro.2007.03.065. PMID 17484894. Unknown parameter |month= ignored (help)
  18. ↑ Banks, PA.; Freeman, ML. (2006). "Practice guidelines in acute pancreatitis". Am J Gastroenterol. 101 (10): 2379–400. doi:10.1111/j.1572-0241.2006.00856.x. PMID 17032204. Unknown parameter |month= ignored (help)
  19. ↑ Martindale, RG.; McClave, SA.; Vanek, VW.; McCarthy, M.; Roberts, P.; Taylor, B.; Ochoa, JB.; Napolitano, L.; Cresci, G. (2009). "Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: Executive Summary". Crit Care Med. 37 (5): 1757–61. doi:10.1097/CCM.0b013e3181a40116. PMID 19373044. Unknown parameter |month= ignored (help)
  20. ↑ Doig, GS.; Heighes, PT.; Simpson, F.; Sweetman, EA.; Davies, AR. (2009). "Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials". Intensive Care Med. 35 (12): 2018–27. doi:10.1007/s00134-009-1664-4. PMID 19777207. Unknown parameter |month= ignored (help)
  21. ↑ Heyland, DK.; Dhaliwal, R.; Drover, JW.; Gramlich, L.; Dodek, P. "Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients". JPEN J Parenter Enteral Nutr. 27 (5): 355–73. PMID 12971736.
  22. ↑ Fang, JC.; Delegge, MH. (2011). "Enteral feeding in the critically ill: the role of the gastroenterologist". Am J Gastroenterol. 106 (6): 1032–7, quiz 1038. doi:10.1038/ajg.2011.77. PMID 21468014. Unknown parameter |month= ignored (help)
  23. ↑ Eatock, FC.; Chong, P.; Menezes, N.; Murray, L.; McKay, CJ.; Carter, CR.; Imrie, CW. (2005). "A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis". Am J Gastroenterol. 100 (2): 432–9. doi:10.1111/j.1572-0241.2005.40587.x. PMID 15667504. Unknown parameter |month= ignored (help)
  24. ↑ Singh, N.; Sharma, B.; Sharma, M.; Sachdev, V.; Bhardwaj, P.; Mani, K.; Joshi, YK.; Saraya, A. (2012). "Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial". Pancreas. 41 (1): 153–9. doi:10.1097/MPA.0b013e318221c4a8. PMID 21775915. Unknown parameter |month= ignored (help)
  25. ↑ Kumar, A.; Singh, N.; Prakash, S.; Saraya, A.; Joshi, YK. "Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes". J Clin Gastroenterol. 40 (5): 431–4. PMID 16721226.
  26. ↑ Eckerwall, GE.; Axelsson, JB.; Andersson, RG. (2006). "Early nasogastric feeding in predicted severe acute pancreatitis: A clinical, randomized study". Ann Surg. 244 (6): 959–65, discussion 965-7. doi:10.1097/01.sla.0000246866.01930.58. PMID 17122621. Unknown parameter |month= ignored (help)
  27. ↑ McClave, SA.; Chang, WK.; Dhaliwal, R.; Heyland, DK. "Nutrition support in acute pancreatitis: a systematic review of the literature". JPEN J Parenter Enteral Nutr. 30 (2): 143–56. PMID 16517959.
  28. ↑ Petrov, MS.; Pylypchuk, RD.; Emelyanov, NV. (2008). "Systematic review: nutritional support in acute pancreatitis". Aliment Pharmacol Ther. 28 (6): 704–12. PMID 19145726. Unknown parameter |month= ignored (help)
  29. ↑ Al-Omran, M.; Albalawi, ZH.; Tashkandi, MF.; Al-Ansary, LA. (2010). "Enteral versus parenteral nutrition for acute pancreatitis". Cochrane Database Syst Rev (1): CD002837. doi:10.1002/14651858.CD002837.pub2. PMID 20091534.
  30. ↑ Marik, PE.; Zaloga, GP. (2004). "Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis". BMJ. 328 (7453): 1407. doi:10.1136/bmj.38118.593900.55. PMID 15175229. Unknown parameter |month= ignored (help)
  31. ↑ Casaer, MP.; Mesotten, D.; Hermans, G.; Wouters, PJ.; Schetz, M.; Meyfroidt, G.; Van Cromphaut, S.; Ingels, C.; Meersseman, P. (2011). "Early versus late parenteral nutrition in critically ill adults". N Engl J Med. 365 (6): 506–17. doi:10.1056/NEJMoa1102662. PMID 21714640. Unknown parameter |month= ignored (help)
  32. ↑ 32.0 32.1 Kutsogiannis, J.; Alberda, C.; Gramlich, L.; Cahill, NE.; Wang, M.; Day, AG.; Dhaliwal, R.; Heyland, DK. (2011). "Early use of supplemental parenteral nutrition in critically ill patients: results of an international multicenter observational study". Crit Care Med. 39 (12): 2691–9. doi:10.1097/CCM.0b013e3182282a83. PMID 21765355. Unknown parameter |month= ignored (help)
  33. ↑ Tan, W.; Barnett, JV.; Hehn, GM.; Quay, SC.; Galper, JB. (1991). "Effect of manganese (II) bis(glycinate)dichloride on Ca2+ channel function in cultured chick atrial cells". Toxicology. 68 (1): 63–73. PMID 1714640.
  34. ↑ Olesen, SS.; Graversen, C.; Bouwense, SA.; van Goor, H.; Wilder-Smith, OH.; Drewes, AM. (2013). "Quantitative sensory testing predicts pregabalin efficacy in painful chronic pancreatitis". PLoS One. 8 (3): e57963. doi:10.1371/journal.pone.0057963. PMID 23469256.
  35. ↑ Wu, BU.; Johannes, RS.; Kurtz, S.; Banks, PA. (2008). "The impact of hospital-acquired infection on outcome in acute pancreatitis". Gastroenterology. 135 (3): 816–20. doi:10.1053/j.gastro.2008.05.053. PMID 18616944. Unknown parameter |month= ignored (help)
  36. ↑ Tenner, S.; Baillie, J.; DeWitt, J.; Vege, SS. (2013). "American College of Gastroenterology guideline: management of acute pancreatitis". Am J Gastroenterol. 108 (9): 1400–15, 1416. doi:10.1038/ajg.2013.218. PMID 23896955. Unknown parameter |month= ignored (help)
  37. ↑ Trikudanathan, G.; Navaneethan, U.; Vege, SS. (2011). "Intra-abdominal fungal infections complicating acute pancreatitis: a review". Am J Gastroenterol. 106 (7): 1188–92. doi:10.1038/ajg.2010.497. PMID 21731015. Unknown parameter |month= ignored (help)

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