MANAGEMENT OF ACUTE PANCREATITIS
non- operative management
repeated and careful clinical assessment of all patients during the first 25 hours is essential as the course of the disease is unpredictable during this time . a chest radiography is mandatory as is estimation of arterial blood gases daily for the first 48 hours and oxygen should be administered by mask if there is hypoxaemia . plain abdominal radiographs may show a sentinel loop, pancreatic calcification or calcified gall stones . vital signs and urine output should be monitored hourly . the severely affected patient should be managed on the intensive care unit . oral intake is withheld so adequate fluid replacement , especially of colloid is necessary . energetic fluid replacement is the single most important therapeutic measure since a large volume of protein rich fluid is sequestered in the
retroperitoneum . volume replacement should be guided by central venous pressure measurement at the first sign of hypovolamia as hypotension or low urine output , a large series showed an improved outcome in those given parenteral antibiotics in a severe attack parenteral nutrition will be necessary . adequate pain control is important an intravenous infusion of morphine or patient controlled analgesia are both preferable to repeated intramuscular boluses . at present there are no specific non operative measures that have been shown to improve outcome in acute pancreatitis as antiproteases or peritoneal lavage . all patients require an abdominal ultrasound to exclude gall stone and if the attack is severe an early CT scan with intravenous contrast to assess pancreatitis viability
Surgical management
Early ERCP
ERCP and sphincterotomy in patients with particularly gall stone pancreatitis results in significantly fewer major complications however the urgent diagnosis of gall stones in acute pancreatitis can be difficult . there is a risk of excacerbating the attack and emergency ERCP can be difficult to arrange
Pancreatic necrosis
. In a small proportion of patients a severe episode is evident from outset or there is early deterioration despite full supportive measures the major determinant of outcome in these cases is the prompt recognition of generalized pancreatic necrosis . in these patients surgery may be necessary to prevent sequential organ failure , sepsis and death . surgery should be delayed for several days as this result in demarcation of necrotic tissue while the patient is optimized on the intensive care unit and allows for safe debridement at laparotomy (pancreatic necrosectomy ) following this the abdomen can be closed with large silicone tubes left in the cavity that can be irrigated postoperatively (closed drainage). alternatively the abdomen is left open (laparostomy)but covered by moist packs should repeated re- exploration and debridement prove necessary , as in occasionally the case . infected pancreatic necrosis or abscess requires drainage either percutaneously or at laparotomy . drainage tubes are left in situ for irrigation with antiseptic or antibiotic solutions
Preventative management
as early cholecystectomy prevents recurrent episodes in patients with gall stones . early cholecystectomy refers to surgery undertaken within twp weeks after the onset of symptoms . immediate surgery is associated with an increased incidence of postoperative complications , particularly an excacerbation of pancreatitis . while deferring operation to a subsequent admission may result in 30-4-% risk of another attack . gall stones should be sought in all patients with acute pancreatitis including those with alcohol induced disease . ERCP is indicated after an episode of idiopathic pancreatitis , though a surgically treatable cause is rarely found
non- operative management
repeated and careful clinical assessment of all patients during the first 25 hours is essential as the course of the disease is unpredictable during this time . a chest radiography is mandatory as is estimation of arterial blood gases daily for the first 48 hours and oxygen should be administered by mask if there is hypoxaemia . plain abdominal radiographs may show a sentinel loop, pancreatic calcification or calcified gall stones . vital signs and urine output should be monitored hourly . the severely affected patient should be managed on the intensive care unit . oral intake is withheld so adequate fluid replacement , especially of colloid is necessary . energetic fluid replacement is the single most important therapeutic measure since a large volume of protein rich fluid is sequestered in the
retroperitoneum . volume replacement should be guided by central venous pressure measurement at the first sign of hypovolamia as hypotension or low urine output , a large series showed an improved outcome in those given parenteral antibiotics in a severe attack parenteral nutrition will be necessary . adequate pain control is important an intravenous infusion of morphine or patient controlled analgesia are both preferable to repeated intramuscular boluses . at present there are no specific non operative measures that have been shown to improve outcome in acute pancreatitis as antiproteases or peritoneal lavage . all patients require an abdominal ultrasound to exclude gall stone and if the attack is severe an early CT scan with intravenous contrast to assess pancreatitis viability
Surgical management
Early ERCP
ERCP and sphincterotomy in patients with particularly gall stone pancreatitis results in significantly fewer major complications however the urgent diagnosis of gall stones in acute pancreatitis can be difficult . there is a risk of excacerbating the attack and emergency ERCP can be difficult to arrange
Pancreatic necrosis
. In a small proportion of patients a severe episode is evident from outset or there is early deterioration despite full supportive measures the major determinant of outcome in these cases is the prompt recognition of generalized pancreatic necrosis . in these patients surgery may be necessary to prevent sequential organ failure , sepsis and death . surgery should be delayed for several days as this result in demarcation of necrotic tissue while the patient is optimized on the intensive care unit and allows for safe debridement at laparotomy (pancreatic necrosectomy ) following this the abdomen can be closed with large silicone tubes left in the cavity that can be irrigated postoperatively (closed drainage). alternatively the abdomen is left open (laparostomy)but covered by moist packs should repeated re- exploration and debridement prove necessary , as in occasionally the case . infected pancreatic necrosis or abscess requires drainage either percutaneously or at laparotomy . drainage tubes are left in situ for irrigation with antiseptic or antibiotic solutions
Preventative management
as early cholecystectomy prevents recurrent episodes in patients with gall stones . early cholecystectomy refers to surgery undertaken within twp weeks after the onset of symptoms . immediate surgery is associated with an increased incidence of postoperative complications , particularly an excacerbation of pancreatitis . while deferring operation to a subsequent admission may result in 30-4-% risk of another attack . gall stones should be sought in all patients with acute pancreatitis including those with alcohol induced disease . ERCP is indicated after an episode of idiopathic pancreatitis , though a surgically treatable cause is rarely found
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