Management of severe acute pancreatitis

Abstract

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

Practice Guidelines in Acute Pancreatitis

“…Guidelines (2, 4, 6, 7) and review articles (9)(10)(11)(12) have generally suggested that surgery be performed promptly or have left unsaid the exact timing of surgery. However, one recent guideline specified that surgical debridement be performed for patients with infected necrosis who are "septic" (3).…”

“…These and subsequent guidelines (2-7) have undergone periodic review (6,(8)(9)(10)(11)(12)(13) in accordance with advances that have been made in the diagnosis and treatment of acute pancreatitis. Guidelines for clinical practice are intended to apply to all health-care providers who take care of patients with acute pancreatitis and are intended to be flexible, and to suggest preferable (but not the only) approaches.…”

History and Evolution of the Management of Acute Pancreatitis

“…In patients with mild to moderate pancreatitis, gastrointestinal rest with adequate fluid resuscitation is usually sufficient initial management. The oral route for feeding should be re-established as soon as the nausea subsides, and provided that the pain does not reappear upon feeding (1,2,6,52,53,73,74,75).…”

“…Recent studies of the physiology of the gastrointestinal tract have demonstrated benefits of enteral feeding especially related to its trophic effects on the intestinal tract (53,74,76,77).…”

“…Accordingly, use of a jejunal tube to start enteral feeding in patients with severe pancreatitis can be attempted only cautiously when the ileus resolves and the condition of the patient allows this intervention (53,74,78,79). Moreover, it is strongly recommended that enteral feeding be accomplished by a tube with its tip one meter distal to the ligament of Treitz (73,75).…”