Pancreatitis is a rapidly onsetting inflammation of the pancreas. Depending on its severity, it can have severe complications and high mortality despite treatment. While mild cases are often successfully treated with conservative measures, such as NPO (abstaining from any oral intake) and IV fluid rehydration, severe cases may require admission to the ICU or even surgery (often more than one intervention) to deal with complications of the disease process.
Symptoms of acute pancreatitis include nausea, upper abdominal pain and fever. Symptoms of chronic pancreatitis include pain after eating and, if advanced, diabetes mellitus and diarrhea from digestive failure. Diagnostic tests for pancreatitis include blood tests, ultrasound and CT scans, as well as endoscopic tests and pancreatic function tests. These tests help physicians determine if surgery or endoscopic therapy is necessary.
Treatment of Pancreatitis
The different treatment modalities for management of chronic pancreatitis are medical measures, therapeutic endoscopy and surgery. Treatment is directed, when possible, to the underlying cause, and to relief of the pain and malabsorption.
Diabetes may occur and need long term insulin therapy (Type 3 diabetes). The abdominal pain can be very severe and require high doses of analgesics. Disability and mood problems are common, although early diagnosis and support can make these problems manageable.
- In the management of acute pancreatitis, the treatment is to stop feeding the patient, giving him or her nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest.Approximately 20% of patients have a relapse of pain during acute pancreatitis. Approximately 75% of relapses occur within 48 hours of oral refeeding. The incidence of relapse after oral refeeding may be reduced by post-pyloric enteral rather than parenteral feeding prior to oral refeeding. IMRIE scoring is also useful.
- Mild cases of acute pancreatitis generally improve in a week or less. Moderate to severe cases take longer to improve. Severe acute pancreatitis usually requires a longer hospital stay; patients with complications may be admitted to the intensive care unit.
- Enzyme supplements such as pancrelipase can help treat problems with maldigestion. By replacing missing enzymes, these tablets help restore normal digestion and alleviate steatorrhea, leading to weight gain and enhanced well-being. Depending on the enzyme preparation used, patients may take up to eight tablets with meals—two tablets after eating a few bites, four during the meal and two after the meal or with snacks.
- Acute pancreatitis usually requires hospital treatment. The main goals of treatment for chronic pancreatitis are to stop alcohol intake (if alcohol is the cause), control pain and improve malabsorption problems. Surgery may be needed for cysts resulting from chronic pancreatitis or in severe cases of acute pancreatitis in which pancreas tissue dies. Complications of pancreatitis are often managed with endoscope procedures.
- When gallstones pass into the common bile duct, acute pancreatitis can occur. Physicians may recommend a procedure—endoscopic retrograde cholangiopancreatography (ERCP)—to remove the stones remaining in the bile duct. Read more about the ERCP procedure on the National Institutes of Health website. Eventually, to prevent future attacks of gallstone pancreatitis, removing the gallbladder in surgery is recommended.
- Recently, there has been a shift in the management paradigm from TPN (total parenteral nutrition) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). The advantage of enteral feeding is that it’s more physiological, prevents gut mucosal atrophy, and is free from the side effects of TPN (such as fungemia). The additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration.Disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the bronchus even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent NG tube entry into the trachea).
- An early randomized controlled trial of imipenem—with 0.5 gram intravenously given every eight hours for two weeks—showed a reduction in from pancreatic sepsis from 30% to 12%. Another randomized controlled trial with patients who had at least 50% pancreatic necrosis found a benefit from imipenem compared to pefloxacin with a reduction in infected necrosis from 34% to 20%.A subsequent randomized controlled trial that used meropenem 1 gram intravenously every 8 hours for 7 to 21 days stated no benefit; however, 28% of patients in the group subsequently required open antibiotic treatment versus 46% in the placebo group. In addition, the control group had only 18% incidence of peripancreatic infections and less biliary pancreatitis that the treatment group (44% versus 24%)
- Early ERCP (endoscopic retrograde cholangiopancreatography), performed within 24 to 72 hours of presentation, is known to reduce morbidity and mortality. The indications for early ERCP are as follows: Clinical deterioration or lack of improvement after 24 hours and detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on CT abdomen.The disadvantages of ERCP are as follows: ERCP precipitates pancreatitis, and can introduce infection to sterile pancreatitis plus the inherent risks of ERCP, i.e., bleeding. It’s also worth noting that ERCP itself can be a cause of pancreatitis.
- Surgery is indicated for infected pancreatic necrosis, diagnostic uncertainty and complications. The most common cause of death in acute pancreatitis is secondary infection. Infection is diagnosed based on 2 criteria: Gas bubbles on CT scan (present in 20% to 50% of infected necrosis) and positive bacterial culture on FNA (fine needle aspiration, usually CT- or US-guided) of the pancreas.
Surgical options for infected necrosis include: Conventional management or necrosectomy with simple drainage, closed management or necrosectomy with closed continuous lavage and open management or necrosectomy with planned staged reoperations at definite intervals (up to 7 reoperations in some cases). On the other hand, surgery for chronic pancreatitis tends to be divided into two areas—resectional and drainage procedures.
- Since chronic pancreatitis can sometimes trigger diabetes, treatment usually involves maintaining a healthy diet and exercise regularly. Some patients also need insulin injections, although insulin must be used cautiously to avoid low blood sugar (hypoglycemia). Doctors inform patients how to manage diabetes, recognize symptoms of high and low blood sugar and prevent complications.
- Pain relief is probably the most important step in treating alcohol-related pancreatitis. In the disease’s early stages, abstinence from alcohol may relieve even severe pain. As pancreatitis progresses, continued alcohol use greatly increases the risk of complications and death; patients who continue drinking have a death rate three times higher than those who abstain.
- Unlike acute pancreatitis, where pain often disappears within a few days to weeks, chronic pancreatitis pain can linger. This is challenging, because conventional pain relievers are often ineffective and pose a risk of addiction. As such, a multidisciplinary team of gastroenterologists, radiologists, surgeons, endoscopic therapists and pain medicine specialists usually utilize behavioral modification and medications to limit narcotic use.
Originally, it was thought that analgesia shouldn’t be provided by morphine because it may cause spasm of the sphincter of Oddi and worsen the pain, so the drug of choice was meperidine. However, due to lack of efficacy and risk of toxicity of meperidine, more recent studies have found morphine the analgesic of choice. Conversely, doctors may recommend eating smaller meals and limiting fats, to help reduce the need for digestive enzymes.
- Replacement pancreatic enzymes are often effective in treating the malabsorption and steatorrhea. However, the outcome from six randomized trials has been inconclusive regarding pain reduction. While the outcome of trials regarding pain reduction with pancreatic enzyme replacement is inconclusive, some patients do have pain reduction with enzyme replacement and since they are relatively safe, giving enzyme replacement to a chronic pancreatitis patient is an acceptable step in treatment for most patients.Treatment may be more likely to be successful in those without involvement of large ducts and those with idiopathic pancreatitis. Patients with alcoholic pancreatitis may be less likely to respond.
In any case, now that you know most everything there is to know about acute and chronic pancreatitis, your pancreatic health will be safe once again. Just remember to make use of these tips and information before it’s too late. Treatment goals include controlling pain, allowing the pancreas to rest and restoring a normal balance of fluid and electrolytes.
Because the pancreas is active when eating, patients generally receive fluids intravenously until inflammation subsides. If alcohol use is the cause of pancreatitis, treatment for alcohol abuse/chemical dependency is recommended. If you learn from reading this article, you’ll surely be interested in learning how to prevent diabetes.
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