Emergent Management of Pancreatitis
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Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. Patients can present in the emergency department (ED) with acute pancreatitis, in which the pancreas can sometimes heal without any impairment of function or any morphologic changes, or they may present with chronic pancreatitis, in which individuals suffer recurrent, intermittent attacks that contribute to the functional and morphologic loss of the gland.
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Most of the pancreatitis cases presenting to the emergency department (ED) are treated conservatively, which includes fluid resuscitation, pain management, and sepsis control. Approximately 80% of patients with pancreatitis respond to such treatment. [1, 2, 3]
Fluid resuscitation includes the following:
Monitoring the patient’s fluid intake/output accurately and electrolyte balance
Infusion with crystalloids or other fluids, such as packed red blood cells (PRBCs), particularly in the case of hemorrhagic pancreatitis
Placement of central lines and Swan-Ganz catheters for patients with severe fluid loss and very low blood pressure
If the patient is not vomiting well, a nasogastric (NG) tube is not necessary, but if the patient is vomiting continuously, then an NG tube is warranted for symptomatic relief and to avoid aspiration.
Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of morphine on the sphincter of Oddi. [4]
Antibiotics are used in severe cases associated with septic shock or when computed tomography (CT) scanning indicates that a phlegmon of the pancreas has evolved. Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third-generation cephalosporins.
Continuous oxygen saturation should be monitored by pulse oximetry, and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed.
Transfer patients with Ranson scores of 0-2 to a hospital floor.
Transfer patients with Ranson scores 3-5 to an intensive care unit (ICU). [5]
Transfer patients with Ranson scores higher than 3 to an ICU, with emergency surgery as a possibility, depending on the patient’s progress and findings on abdominal CT scanning.
Computed tomography (CT)-guided aspiration of necrotic areas may be necessary. Endoscopic retrograde cholangiopancreatography (ERCP) may be indicated for common duct stone removal. [6]
Consult a general surgeon in the following cases [7] :
For a phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue; this should be followed by postoperative lavage of the pancreatic bed
In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis
Patients whose condition fails to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room; surgery in these cases may lead to a better outcome or confirm a different diagnosis: One study suggested a minimally invasive step-up approach was associated with less complication, although mortality was similar in the open and minimally invasive groups [8]
In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction; a cholecystectomy may be performed to clear the system from any source of biliary stones
In cases of mild gallstone pancreatitis, one small study of 50 patients found early gallbladder removal was safe and associated with shorter hospital stay [9]
Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. 2006 May 18. 354(20):2142-50. [Medline].
Forsmark CE. Management of chronic pancreatitis. Gastroenterology. 2013 Jun. 144(6):1282-1291.e3. [Medline].
Wu BU, Banks PA. Clinical management of patients with acute pancreatitis. Gastroenterology. 2013 Jun. 144(6):1272-81. [Medline].
Wu SD, Zhang ZH, Jin JZ, Kong J, Wang W, Zhang Q, et al. Effects of narcotic analgesic drugs on human Oddi’s sphincter motility. World J Gastroenterol. 2004 Oct 1. 10(19):2901-4. [Medline].
Pavlidis P, Crichton S, Lemmich Smith J, Morrison D, Atkinson S, Wyncoll D, et al. Improved outcome of severe acute pancreatitis in the intensive care unit. Crit Care Res Pract. 2013. 2013:897107. [Medline].
Bahr MH, Davis BR, Vitale GC. Endoscopic management of acute pancreatitis. Surg Clin North Am. 2013 Jun. 93(3):563-84. [Medline].
Martin RF, Hein AR. Operative management of acute pancreatitis. Surg Clin North Am. 2013 Jun. 93(3):595-610. [Medline].
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22. 362(16):1491-502. [Medline].
Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg. 2010 Apr. 251(4):615-9. [Medline].
Granger J, Remick D. Acute pancreatitis: models, markers, and mediators. Shock. 2005 Dec. 24 Suppl 1:45-51. [Medline].
Pannala R, Chari ST. Autoimmune pancreatitis. Curr Opin Gastroenterol. 2008 Sep. 24(5):591-6. [Medline].
Plock JA, Schmidt J, Anderson SE, Sarr MG, Roggo A. Contrast-enhanced computed tomography in acute pancreatitis: does contrast medium worsen its course due to impaired microcirculation?. Langenbecks Arch Surg. 2005 Apr. 390(2):156-63. [Medline].
Taylor SL, Morgan DL, Denson KD, Lane MM, Pennington LR. A comparison of the Ranson, Glasgow, and APACHE II scoring systems to a multiple organ system score in predicting patient outcome in pancreatitis. Am J Surg. 2005 Feb. 189(2):219-22. [Medline].
Werner J, Feuerbach S, Uhl W, Büchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut. 2005 Mar. 54(3):426-36. [Medline]. [Full Text].
Whitcomb DC, Yadav D, Adam S, Hawes RH, Brand RE, Anderson MA, et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008. 8(4-5):520-31. [Medline].
Ghattas Khoury, MD Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut, Lebanon
Ghattas Khoury, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.
Samer S Deeba, MD(DrSc) Assistant Professor of Surgery, Department of Surgery and Cancer, Imperial College London
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Emergent Management of Pancreatitis
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