May 27th, 2013 por Isabel Correia
Acute pancreatitis (AP) is a not so rare complication of gallbladder stone disease as well as it maybe an acute flare in patients who make use of chronic ingestion of alcoholic beverages or even after an acute exacerbated intake. Not so frequently pancreatitis is associated to autoimmune diseases or more rarely is of idiopathic origin.
No matter the etiology, early adequate management of this entity is fundamental, especially in severe episodes, in order to prevent increased morbidity and mortality. About 5% of all patients with AP die, but those with severe AP present with mortality rate of 19-30%.
The severity of pancreatitis maybe determined by different methods, such as the severity Apache score, the tomography criteria of Baltazar and, the Ranson clinical and laboratorial criteria, still much in use. However, more recently criteria have been advocated such as the Bedside Index for Severity of Acute Pancreatitis (BISAP). This score has the advantage of being calculated with variables available in the first 24 hours: blood urea nitrogen (BUN) greater than 25 mg/dl, impaired mental status (Glasgow Coma Score less than 15), presence of the systemic inflammatory response syndrome, age greater than 60 years, and pleural effusion detected on imaging. Each positive variable adds one point to the total score, and scores of 3, 4, and 5 correspond to a hospital mortality of 5.3, 12.7, and 22.5%, respectively. Another score is the Harmless Acute Pancreatitis Score (HAPS) which includes three factors that can be measured within 30 minutes of admission: absence of rebound tenderness and/or guarding, normal hematocrit, and normal serum creatinine. HAPS can predict a nonsevere disease course with 96–97% specicity and 98% positive predictive value.
Mild to moderate flares can be treated with nil per os, fluid infusion and analgesia. Usually the clinical conditions improve within 48 to 72 hours and the patients are back to routine oral intake and regular life. On the other hand, severe acute pancreatitis is associated with high morbidity and mortality and the initial treatment impacts on the outcome.
Fluid resuscitation is a cornerstone in the treatment of AP during the first 24 hours because perfusion of the microcirculation of the pancreas and the intestine in order to prevent intestinal ischemia and subsequent bacterial translocation and secondary pancreatic infection is fundamental. Thus, intravenous fluids should guarantee at least 0.5 mL/kg/h of urine output and a Foley catheter should be placed.
The use of prophylactic antibiotics given at the time of detection of pancreatic necrosis in severe AP has been an area of considerable debate with some studies pointing to the advantage of prophylactic antibiotics, such as Imipem and others declining such benefit. The most recent meta-analysis, published in 2011, reviewed 14 trials with a total of 841 patients and no difference in rates of mortality or infection was detected with the use of antibiotics. On the other hand, prolonged prophylactic antibiotics are associated with the development of intra-abdominal fungal infections. Therefore, prophylactic antibiotics are not recommended in AP and should not be given in the first 24 hours to prevent infection.
In cases of biliary acute pancreatitis, ERCP should not be routinely performed, including those with choledocholithiasis, within the first 24 hours. The only indications for ERCP within the first day are AP complicated by ascending cholangitis or (ii) the development of a worsening clinical course in the context of increasing liver tests.
Another key approach is failure to utilize the gastrointestinal (GI) tract in patients with acute pancreatitis which may exacerbate the organic response and disease severity, leading to greater incidence of complications, prolonged hospitalization and increased mortality. Therefore, nutritional therapy in the form of enteral feeding has been shown to favorably impact this burden of disease in patients with severe acute pancreatitis, providing the opportunity to change the course of illness, reduce complications, attenuate oxidative stress, and promote faster recovery and resolution of the disease process. The concept of‘ putting the pancreas to rest was regarded as a key element in the early management of acute pancreatitis. For decades patients received total parenteral nutrition in an attempt to avoid stimulation of pancreatic enzymes secretion, which over time has been shown to adversely impact on the outcome. Currently, enteral nutrition, preferentially, oligomeric formula, is indicated as the golden route and, this can be administered either in the stomach or in the jejunum, depending on the patient’s tolerance.
1. Balthazar EJ, Fisher LA. Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging. Pancreatology : official journal of the International Association of Pancreatology. 2001;1(4):306-13. PubMed PMID: 12120209.
2. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11. PubMed PMID: 23100216.
3. Dellinger EP, Forsmark CE, Layer P, Levy P, Maravi-Poma E, Petrov MS, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Annals of surgery. 2012 Dec;256(6):875-80. PubMed PMID: 22735715.
4. Fisher JM, Gardner TB. The “golden hours” of management in acute pancreatitis. The American journal of gastroenterology. 2012 Aug;107(8):1146-50. PubMed PMID: 22858994.
5. Heinrich S, Schafer M, Rousson V, Clavien PA. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Annals of surgery. 2006 Feb;243(2):154-68. PubMed PMID: 16432347. Pubmed Central PMCID: 1448904.
6. Petrov MS, Chong V, Windsor JA. Infected pancreatic necrosis: not necessarily a late event in acute pancreatitis. World journal of gastroenterology : WJG. 2011 Jul 21;17(27):3173-6. PubMed PMID: 21912463. Pubmed Central PMCID: 3158390.
7. Petrov MS, Correia MI, Windsor JA. Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. JOP : Journal of the pancreas. 2008;9(4):440-8. PubMed PMID: 18648135.
8. Petrov MS, Vege SS, Windsor JA. Global survey of controversies in classifying the severity of acute pancreatitis. European journal of gastroenterology & hepatology. 2012 Jun;24(6):715-21. PubMed PMID: 22382706.
9. Petrov MS, Windsor JA. Conceptual framework for classifying the severity of acute pancreatitis. Clinics and research in hepatology and gastroenterology. 2012 Aug;36(4):341-4. PubMed PMID: 22551642.
10. Petrov MS, Windsor JA. Severity of acute pancreatitis: impact of local and systemic complications. Gastroenterology. 2012 Jun;142(7):e20-1; author reply e1. PubMed PMID: 22542833.
11. Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane database of systematic reviews. 2010 (5):CD002941. PubMed PMID: 20464721.
12. Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2011 Aug;9(8):705-9. PubMed PMID: 21554987. Pubmed Central PMCID: 3143229.
13. Windsor JA, Petrov MS. Acute pancreatitis reclassified. Gut. 2013 Jan;62(1):4-5. PubMed PMID: 23139196.
14. Wittau M, Hohl K, Mayer J, Henne-Bruns D, Isenmann R. The weak evidence base for antibiotic prophylaxis in severe acute pancreatitis. Hepato-gastroenterology. 2008 Nov-Dec;55(88):2233-7. PubMed PMID: 19260512.
15. Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R. Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scandinavian journal of gastroenterology. 2011 Mar;46(3):261-70. PubMed PMID: 21067283.
16. Wittau M, Scheele J, Golz I, Henne-Bruns D, Isenmann R. Changing role of surgery in necrotizing pancreatitis: a single-center experience. Hepato-gastroenterology. 2010 Sep-Oct;57(102-103):1300-4. PubMed PMID: 21410076.
17. Wu BU, Johannes RS, Kurtz S, Banks PA. The impact of hospital-acquired infection on outcome in acute pancreatitis. Gastroenterology. 2008 Sep;135(3):816-20. PubMed PMID: 18616944. Pubmed Central PMCID: 2570951.
18. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703. PubMed PMID: 18519429.