Treatment of Pancreatitis
There are a number of steps that need to be taken when treating acute pancreatitis.
Due to very severe pain, analgesics should be administered to the patient. In the past meperidine was administered to patients because it was thought that morphine caused a spasm of the sphincter of Oddi (located right above major duodenal papilla), which would worsen the condition. Recent studies have shown that morphine does not produce this effect and it is much safer to use than meperidine.
No food should be given to the patient. In order to prevent dehydration, intravenous rehydration is carried out. This provides rest for the pancreas, as the food stimulates production of pancreatic enzymes, which can cause a relapse of pain and worsen the condition.
In the past nutritional support of the patients that suffered from acute pancreatitis was provided by parenteral nutrition only. However, in recent years, a post-pyloric enteral feeding is chosen much more often. This method involves passing a feeding tube through the nose into the third portion of the duodenum or into jejunum. It is a preferable method due to it being more physiological and preventing gut mucosal atrophy. It also doesn’t have a serious side effect of fungemia, which sometimes happens as a result of total parenteral nutrition. Adverse effects of this method include sinusitis, especially if the patient is fed using the method for over two weeks. Also, there is always a chance of accidentally intubating the trachea; however, with a few precautions, this happens very rarely.
Antibiotics are used if the patient is suffering from purulent form of acute pancreatitis. Carbapenems (β-lactam antibiotics) are usually used for this purpose. Antibiotics reduce the area of necrosis of the pancreas, greatly improving the prognosis.
Endoscopic retrograde cholangiopancreatography, if used in the first 24-72 hours, has shown to reduce mortality and morbidity. Indications for using this procedure are:
- Lack of improvement in 24 hours of treatment;
- Detection of stones in a common bile duct or detection of dilated extra- or intrahepatic ducts using computed tomography.
This technique involves passing of endoscope into the biliary and pancreatic ducts in order to remove the cause of obstruction (stones, mucus, etc.)
Surgical treatment of acute pancreatitis is indicated for:
- Infected pancreatic necrosis;
- Diagnostic uncertainty;
Secondary infection is the most common cause of death in patients that suffer from acute pancreatitis.
Infection can be diagnosed using two criteria:
- Positive bacterial culture acquired using fine needle aspiration (FNA) under control of ultrasound or computed tomography;
- Gas bubbles on computed tomography scan.
The scope of the surgical procedure varies depending on severity of the process:
- Minimally invasive management – is done through a small incision in the left flank, through which necrosectomy is performed;
- Conventional management – necrosectomy followed by a simple drainage;
- Closed management – necrosectomy followed by closed continuous postoperative lavage;
- Open management – necrosectomy follow by planned reoperations performed at certain intervals.
Methods that have proven to be ineffective
In the past enzyme inhibitors were widely used to decrease the necrosis of pancreatic cells. However, newer studies found that enzyme inhibitors do not produce any effect and do not improve the patient’s condition. Previously used somatostatins, which were thought to decrease pancreatic secretion, reduce pain, and reduce the number of complications, have been proven to be ineffective.
The evaluation of prognosis is a very hard task when it comes to acute pancreatitis. Two scoring systems are used for this purpose: APACHE II and Ranson criteria. Almost all studies have shown that APACHE II is the more accurate of the two.
APACHE II scoring is applied within 24 hours of the patient’s admission to the ICU (intensive care unit). The score can range from 0 to 71. Higher risk of death corresponds with a higher score.
In comparison to other acute inflammatory processes, acute pancreatitis is among the leading causes of death, since very severe complications frequently accompany this disorder.