Acute pancreatitis medical therapy: Difference between revisions
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==== TPN vs. Tube Feeding ==== | ==== 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). | 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).<ref name="pmid22449657">{{cite journal| author=Yi F, Ge L, Zhao J, Lei Y, Zhou F, Chen Z et al.| title=Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis. | journal=Intern Med | year= 2012 | volume= 51 | issue= 6 | pages= 523-30 | pmid=22449657 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22449657 }} </ref> | ||
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. | 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. | ||
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. | 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.<ref name="pmid20091534">{{cite journal| author=Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA| title=Enteral versus parenteral nutrition for acute pancreatitis. | journal=Cochrane Database Syst Rev | year= 2010 | volume= | issue= 1 | pages= CD002837 | pmid=20091534 | doi=10.1002/14651858.CD002837.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20091534 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20643984 Review in: Ann Intern Med. 2010 Jul 20;153(2):JC1-6] </ref><ref name="pmid24054878">{{cite journal| author=Working Group IAP/APA Acute Pancreatitis Guidelines| title=IAP/APA evidence-based guidelines for the management of acute pancreatitis. | journal=Pancreatology | year= 2013 | volume= 13 | issue= 4 Suppl 2 | pages= e1-15 | pmid=24054878 | doi=10.1016/j.pan.2013.07.063 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24054878 }} </ref><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> | ||
TPN may be utilized in the rare cases where enteral feeding is not at all tolerated and nutritional goals are not met. | TPN may be utilized in the rare cases where enteral feeding is not at all tolerated and nutritional goals are not met.<ref name="pmid24054878">{{cite journal| author=Working Group IAP/APA Acute Pancreatitis Guidelines| title=IAP/APA evidence-based guidelines for the management of acute pancreatitis. | journal=Pancreatology | year= 2013 | volume= 13 | issue= 4 Suppl 2 | pages= e1-15 | pmid=24054878 | doi=10.1016/j.pan.2013.07.063 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24054878 }} </ref><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> | ||
==== Timing of Enteric Feeding ==== | ==== Timing of Enteric Feeding ==== | ||
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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 antibiotics. 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.
Fluid Resuscitation
Nutritional Support
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).[2]
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.
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.[3][4][5]
TPN may be utilized in the rare cases where enteral feeding is not at all tolerated and nutritional goals are not met.[4][5]
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.
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.
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
There is no benefit for prophylactic antibiotics in patients with acute pancreatitis unless infection is suspected or confirmed.[6][7][8][9][5][4]
Other Measures
- Pancreatic enzyme inhibitors are not proven to work.[10]
- The use of octreotide has not been shown to improve outcome.[11]
Contraindicated medications
Acute pancreatitis accompanied by hyperlipidemia is considered an absolute contraindication to the use of the following medications:
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.
- ↑ 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
- ↑ 4.0 4.1 4.2 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.
- ↑ 5.0 5.1 5.2 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.
- ↑ 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
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