Treatment

The cornerstone of therapy is to provide supportive care, with adequate volume resuscitation and monitoring of hemodynamic, respiratory, and renal function. The aims of therapy are to reduce pancreatic necrosis and enhance tissue perfusion, limit complications, recognize infected necrosis early, and prevent future attacks.

Resuscitation

Clinical assessment of severity APACHE II, CRP

Clinical assessment of severity APACHE II, CRP

FIGURE 136-2. Management algorithm for acute pancreatitis. APACHE = Acute Physiological and Chronic Health Evaluation; CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography.

General Measures

Severe acute pancreatitis is like a burn with patients developing intravascular volume depletion due to "third spacing" of fluid. Resuscitation begins in the emergency room with normal saline; patients with severe pancreatitis will require 4 to 10 L over the first 24 hours. Intravascular volume assessment should be made regularly using the urine output, vital signs, and mental status. Adequate electrolyte replacement should accompany fluid infusion. In severely ill patients central venous pressure monitoring is useful. A persistently elevated hematocrit may be a sign of inadequate volume replacement and a poor prognostic sign. Abdominal pain is treated with meperidine (Demerol) (50 to 100 mg) given every 4 hours; fentanyl is an alternative medication for this purpose. We avoid the use of morphine because it causes more increase in sphincter of Oddi (SO) pressure. Patients are kept NPO on admission and nasogastric (NG) tube placement is only used for patients with severe disease and an ileus. Gastric acid secretion should be suppressed to prevent stress ulceration. Nasal oxygen should be used for oxygen saturation < 90%. Mechanical ventilation may be required in patients who hypoventilate or develop adult respiratory distress syndrome (ARDS).

Mild Pancreatitis

Patients by mild pancreatitis have a good prognosis and can be managed on a regular medical floor. In addition to supportive care described above, patients are kept NPO until there is a prominent reduction in their abdominal pain. This usually takes 3 to 5 days after which they are started on a low fat diet. There is no indication for enteral feeding or prophylactic antibiotics in this group of patients. NG tube placement is not necessary. When patients are hungry and their symptoms have resolved, they should be fed even if the serum levels of pancreatic enzymes are elevated. If pain occurs with feeding it may reflect unresolved pancreatitis or a disease complication (eg, duct leak).

Severe Pancreatitis

Patients with severe acute pancreatitis are admitted to an intensive care unit for hemodynamic and respiratory monitoring and support. Following adequate resuscitation, a contrast enhanced CT scan of the abdomen is obtained on day 2 or 3, because pancreatic necrosis is best observed at 48 to 72 hours after onset and this delay may minimize the harmful effects of the cT contrast. The patient is kept NPO; NG tube decompression is used in patients with a symptomatic ileus. Hyperglycemia is sometimes observed but it is often mild and transient and requires treatment only when glucose levels are very high. Multiple factors cause a decrease in serum calcium levels during acute pancreatitis. The most common cause is hypoalbuminemia, which results in normal serum ionized calcium, is asymp tomatic, and requires no treatment. Reduced ionized serum calcium with neuromuscular irritability is rare, but requires treatment with cautious administration of IV calcium. Because hypocalcemia may be accompanied by hypomag-nesemia, serum magnesium levels need to be measured in the symptomatic patient. Hypertriglyceridemia observed during an episode of acute pancreatitis generally does not require any specific therapy. Only those with persistently elevated triglyceride levels need to be considered for treatment. A very rare exception may be patients with ARDS and hypertriglyceridemia who may benefit from acute plasmapharesis.

Specific Organ Involvement in Severe Pancreatitis

Pulmonary Patients may develop respiratory failure from pain and ascites, pleural effusions, and ARDS. Respiratory failure form ARDS is the most serious complication and is usually seen in the first week of severe acute pancreatitis. Pulmonary artery wedge pressure (PAWP) measurement must be performed to determine if hypoxemia is due to congestive heart failure (elevated PAWP) or ARDS (normal or low PAWP). There is no specific treatment and patients require support by mechanical ventilation with positive end-expiratory pressure.

Renal Renal dysfunction is common and initially is due to volume depletion and prerenal azotemia. Aggressive volume resuscitation is necessary early in the course of disease. If the renal dysfunction does not resolve, the patient has developed acute tubular necrosis and fluid management requires central venous pressure monitoring.

Cardiovascular Patients may develop congestive cardiac failure or myocardial ischemia. This should be considered in those who do not respond to adequate fluid resuscitation. Once again PAWP determination is helpful in management and patients may require support with pressors.

Gastrointestinal Gastrointestinal bleeding in acute pancreatitis may be due to erosive gastritis, duodenitis from acute pancreatitis, bleeding from a pseudoaneurysm of the gastroduodenal or splenic arteries, gastric variceal bleeding from splenic vein thrombosis (usually associated with chronic pancreatitis), and hemosuccus pancreaticus. Patients should receive blood transfusions to maintain a hematocrit of about 30 and upper endoscopy may be indicated. Arterial embolization is the treatment of choice for pseudoaneurysms. The inflammation of pancreatitis may extend into the transverse mesocolon and result in colonic inflammation presenting as a "colon cut off sign" on abdominal radiograph. No specific treatment is required and this usually resolves, but rarely surgery is required for perforation or bleeding.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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