Acute pancreatitis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
Medical therapy for acute pancreatitis includes pain control, bowel rest, nutritional support, intravenous fluids, and occasionally antiobiotics. ERCP is also a possible treatment for acute pancreatitis, but can also cause pancreatitis.
Medical Therapy
Pain Control
Analgesia should not be provided by morphine because it may cause spasm of the sphincter of Oddi and worsen the pain, so the drug of choice is Meperidine.
Bowel Rest
In the management of acute pancreatitis, the treatment is to stop feeding the patient, giving him or her nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest. Approximately 20% of patients have a relapse of pain during acute pancreatitis.[1] Approximately 75% of relapses occur within 48 hours of oral refeeding.
The incidence of relapse after oral refeeding may be reduced by post-pyloric enteral rather than parenteral feeding prior to oral refeeding.[1] IMRIE scoring is also useful.
Nutritional Support
Recently, there has been a shift in the management paradigm from TPN (total parenteral nutrition) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). The advantage of enteral feeding is that it is more physiological, prevents gut mucosal atrophy, and is free from the side effects of TPN (such as fungemia). The additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration.
Disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the bronchus even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent NG tube entry into the trachea).
Antibiotics
A meta-analysis by the Cochrane Collaboration concluded that antibiotics help with a number needed to treat of 11 patients to reduce mortality [2]. However, the one study in the meta-analysis that used a quinolone, and a subsequent randomized controlled trial that studied ciprofloxacin were both negative [3]. In summary, the role of antibiotics is controversial. One recent expert opinion (prior to the last negative trial of meropenem[4]) suggested the use of imipenem if CT scan showed more than 30% necrosis of the pancreas.[5]
Carbapenems
An early randomized controlled trial of imipenem 0.5 gram intravenously every eight hours for two weeks showed a reduction in from pancreatic sepsis from 30% to 12%. [6]
Another randomized controlled trial with patients who had at least 50% pancreatic necrosis found a benefit from imipenem compared to pefloxacin with a reduction in infected necrosis from 34% to 20%[7]
A subsequent randomized controlled trial that used meropenem 1 gram intravenously every 8 hours for 7 to 21 days stated no benefit; however, 28% of patients in the group subsequently required open antibiotic treatment vs. 46% in the placebo group. In addition, the control group had only 18% incidence of peripancreatic infections and less biliary pancreatitis that the treatment group (44% versus 24%).[4]
Other Measures
- Pancreatic enzyme inhibitors are not proven to work.[8]
- The use of octreotide has not been shown to improve outcome.[9]
References
- ↑ 1.0 1.1 Petrov MS, van Santvoort HC, Besselink MG, Cirkel GA, Brink MA, Gooszen HG (2007). "Oral Refeeding After Onset of Acute Pancreatitis: A Review of Literature". doi:10.1111/j.1572-0241.2007.01357.x. PMID 17573797.
- ↑ Villatoro E, Bassi C, Larvin M. "Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis". Cochrane Database Syst Rev: CD002941. PMID 17054156.
- ↑ Isenmann R, Rünzi M, Kron M, Kahl S, Kraus D, Jung N, Maier L, Malfertheiner P, Goebell H, Beger H (2004). "Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial". Gastroenterology. 126 (4): 997–1004. doi:10.1053/j.gastro.2003.12.050. PMID 15057739.
- ↑ 4.0 4.1 Dellinger EP, Tellado JM, Soto NE; et al. (2007). "Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study". Ann. Surg. 245 (5): 674–83. doi:10.1097/01.sla.0000250414.09255.84. PMID 17457158.
- ↑ Whitcomb D (2006). "Clinical practice. Acute pancreatitis". N Engl J Med. 354 (20): 2142–50. doi:10.1056/NEJMcp054958. PMID 16707751.
- ↑ Pederzoli P, Bassi C, Vesentini S, Campedelli A (1993). "A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem". Surgery, gynecology & obstetrics. 176 (5): 480–3. PMID 8480272.
- ↑ Bassi C, Falconi M, Talamini G; et al. (1998). "Controlled clinical trial of pefloxacin versus imipenem in severe acute pancreatitis". Gastroenterology. 115 (6): 1513–7. PMID 9834279.
- ↑ DeCherney, Alan H. (2003). Current Obstetric & Gynecologic Diagnosis & Treatment. McGraw-Hill Professional. ISBN 0838514014. Unknown parameter
|coauthors=ignored (help) - ↑ Peitzman, Andrew B. (2007). The Trauma Manual: Trauma and Acute Care Surgery. Lippincott Williams
& Wilkins. ISBN 0781762758. Unknown parameter
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