Acute pancreatitis medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
According to the American college of gastroenterology, following are the diagnostic guidelines for acute pancreatitis:<ref name="pmid23896955">{{cite journal| author=Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology| title=American College of Gastroenterology guideline: management of acute pancreatitis. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 9 | pages= 1400-15; 1416 | pmid=23896955 | doi=10.1038/ajg.2013.218 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23896955 }}</ref> | |||
===Initial Management=== | ===Initial Management=== | ||
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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]; Tarek Nafee, M.D. [3]
Overview
The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition.[1]
Medical Therapy
According to the American college of gastroenterology, following are the diagnostic guidelines for acute pancreatitis:[2]
Initial Management
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Aggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution should be provided to all patients unless cardiovascular and/or renal comorbidities exist. Early aggressive intravenous hydration is most beneficial the first 12–24 h, and may have little benefit beyond | Moderate | Strong |
| In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed | Moderate | Conditional |
| Lactated Ringer's solution may be the preferred isotonic crystalloid replacement fluid | Moderate | Conditional |
| Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next 24–48 h. The goal of aggressive hydration should be to decrease the blood urea nitrogen | Moderate | Strong |
Role of Antibiotics
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia | High | Strong |
| Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended | Moderate | Strong |
| The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended | Moderate | Strong |
| Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7–10 days of hospitalization. In these patients, either (i) initial CT-guided fine needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or (ii) empiric use of antibiotics without CT FNA should be given | Low | Strong |
| In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in delaying or sometimes totally avoiding intervention, thus decreasing morbidity and mortality | Low | Conditional |
| Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended | Low | Conditional |
Nutrition in Acute Pancreatitis
| Recommendation | Evidence Level | Strength of Recommendation |
|---|---|---|
| In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and abdominal pain has resolved | Moderate | Conditional |
| In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet | Moderate | Conditional |
| In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided unless the enteral route is not available, not tolerated, or not meeting caloric requirements | High | Strong |
| Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety | Moderate | Strong |
The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and serial imaging findings. Antibiotics may only be used in cases when infection is suspected or confirmed.[1]
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.[3][2][1]
Bowel Rest
In the management of acute pancreatitis, the initial steps involve bowel rest and placing the patient as NPO (nothing by mouth).[3][2][1]
Fluid Resuscitation
Aggressive fluid therapy is of utmost importance from 12-24 hrs after onset of symptoms. There is little value beyond this point. Normal saline or Ringer's lactate should be administered at a rate of 200-500 mL/hr within the first 24 hours.[3][2] Fluid status should be monitored with hourly urine output, BUN and hematocrit. Resistence of normalization of BUN and hematocrit despite adequate fluid resuscitation is associated with a poor prognosis.[1]
Clinicians should be wary of volume overload, particularly in patients with underlying CHF or renal dysfunction. In those patients, fluid therapy should be individualized according to renal and cardiac tolerance as well as close monitoring of clinical manifestations of fluid overload (e.g. edema, dyspnea, electrolyte imbalance, and symptoms of compartment syndrome).[3][2]
Nutritional Support
Traditionally, complete resolution of pain was a requirement prior to initiation of oral feeding. However, as of late, a low-fat soft or solid diet has been found to benefit patients with shorter durations of hospitalization than slower advancements to solid foods in patients with mild pancreatitis in the absence of organ failure or pancreatic necrosis.
Approximately 20% of patients have a relapse of pain during acute pancreatitis.[4] 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.[4] IMRIE scoring may be a useful tool in assessing the optimal initiation of refeeding.[1]
TPN vs. Tube Feeding
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).[5]
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 tube feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration.[6][3][2]
TPN may be utilized in the rare cases where enteral feeding is not at all tolerated and nutritional goals are not met.[3][2]
Timing of Enteric Feeding
The need for enteral feeding should be assessed by day 5, at latest, based on ongoing assessment of symptoms and the ability to tolerate oral feeds. In milder cases, oral diet should be attempted at 72 hours when symptoms improve and tube feeding only be attempted in cases when oral feeding is not tolerated for 2 to 3 days. Switching from oral to tube feeding should only be considered when oral feeding shows no improvement or worsening of symptoms at 3 to 5 day intervals.[2][1]
Types of Tube Feeding
Naso-jejunal tube feeding is known to minimize pancreatic secretions; however, nasogastric and nasoduodenal feeding are associated with similar patient outcomes.[2]
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).[1]
Antibiotics
There is no benefit for prophylactic antibiotics in patients with acute pancreatitis unless infection is suspected or confirmed.[7][8][9][10][2][3][1]
Other Measures
- Pancreatic enzyme inhibitors are not proven to work.[11]
- The use of octreotide has not been shown to improve outcome.[12]
Contraindicated medications
Acute pancreatitis accompanied by hyperlipidemia is considered an absolute contraindication to the use of the following medications:
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Forsmark CE, Vege SS, Wilcox M (November 17,2016). "Acute Pancreatitis". The New England Journal of Medicine: 1972–1981. doi:10.1056/NEJMra1505202. Retrieved November 25,2016. Check date values in:
|access-date=, |date=(help) - ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 Tenner S, Baillie J, DeWitt J, Vege SS, American College of Gastroenterology (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.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Working Group IAP/APA Acute Pancreatitis Guidelines (2013). "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.
- ↑ 4.0 4.1 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.
- ↑ Yi F, Ge L, Zhao J, Lei Y, Zhou F, Chen Z; et al. (2012). "Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis". Intern Med. 51 (6): 523–30. PMID 22449657.
- ↑ 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. Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-6
- ↑ Isenmann R, Rünzi M, Kron M, Kahl S, Kraus D, Jung N; et al. (2004). "Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial". Gastroenterology. 126 (4): 997–1004. PMID 15057739.
- ↑ Dellinger EP, Tellado JM, Soto NE, Ashley SW, Barie PS, Dugernier T; 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. PMC 1877078. PMID 17457158.
- ↑ Lim CL, Lee W, Liew YX, Tang SS, Chlebicki MP, Kwa AL (2015). "Role of antibiotic prophylaxis in necrotizing pancreatitis: a meta-analysis". J Gastrointest Surg. 19 (3): 480–91. doi:10.1007/s11605-014-2662-6. PMID 25608671.
- ↑ Villatoro E, Mulla M, Larvin M (2010). "Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis". Cochrane Database Syst Rev (5): CD002941. doi:10.1002/14651858.CD002941.pub3. PMID 20464721.
- ↑ 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
|coauthors=ignored (help); line feed character in|publisher=at position 20 (help)