Update on the management of acute pancreatitis

Abstract

Purpose of reviewThis review provides insight into the recent advancements in the management of acute pancreatitis.Recent findingsModerate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal “on-demand” diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis.SummaryMore treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.

Targeting ductal-endothelial crosstalk alleviate pancreatitis

“…Severe acute pancreatitis can lead to complications such as sepsis or multiorgan failure(10). But current treatments are mainly supportive care, including intravenous fluid administration, antibiotics to prevent further infection, and pain-killer for patient’s pain management(11). Surgery is utilized to remove damaged pancreatic tissue or obstructive gallstone(12, 13).…”

Renal Abscess Drainage Using a Novel Transgastric Endoscopic Approach: A Case Report

“…This case report describes a novel approach to renal abscess drainage using a transgastric approach which has been used before in Roux-en-Y gastric bypass gastric bypass patients, multiple pancreatic conditions, and gallbladder drainage [ 6 - 13 ]. To our knowledge, this is the first description of an endoscopic ultrasound (EUS)-guided technique with the placement of a stent specifically between a renal abscess and the stomach for drainage.…”

The power of the gut in critical care

“…The management of acute pancreatitis, which is centered around fluid resuscitation, nutrition, and pain management, is constantly improving. The authors clearly describe the current trend towards a more conservative approach, which involves using fewer fluids, less opiates, and delaying interventions as much as possible [14]. Approaches that used probiotics or immunomodulation have so far not demonstrate any meaningful effect on clinical important outcomes in patients with severe pancreatitis.…”

“…Approaches that used probiotics or immunomodulation have so far not demonstrate any meaningful effect on clinical important outcomes in patients with severe pancreatitis. Van den Berg et al [14] conclude that first we need a more fundamental understanding of the role of the gut, the microbiome and the early inflammatory response in pancreatitis.…”

“…Finally, Van den Berg et al [14] provide an update of the treatment of severe pancreatitis. The gut microbiome is altered in patients with acute pancreatitis, and the microbes responsible for secondary infection in necrotizing pancreatitis often originate from the gastrointestinal tract [15].…”