Pancreatitis medical therapy

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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]

Overview

Pancreatitis is first classified according to severity and duration and then treated accordingly. Initial management include rehydrating the patient, managing pain, restoring nutrients via parenteral route and preventing complications.

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.

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 surrounding the 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

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.

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.
• 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)
• Fluid rate should be based on
  • Clinical evaluation
  • Hematocrit
  • Blood urea nitrogen (BUN)
• The goal of fluid management should be evaluated by :
  • 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.
• Aggressive treatment in the first few hours of presentation have shown to reduce mortality.
• A research study states that dehydration lasting more than 24 hours may lead to necrotizing pancreatitis. Necrotizing pancreatitis leads to third space loss and in turn causes decreased circulation in the pancreas.

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. 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.

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.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.
• 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.

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. A study revealed that enteral feeding alone had less mortality compared to combined enteral and parenteral feeding. A 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.

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.

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