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SSAT Patient Care Guidelines

Treatment of Acute Pancreatitis

Introduction
The severity of acute pancreatitis ranges from edema to necrosis of the gland. The edematous form of the disease occurs in about 80-85% of patients and is self-limited, with recovery in a few days. In the 15-20% of patients with the most severe form of pancreatitis, hospitalization is prolonged and commonly associated with infection and other complications including multiple organ failure. Operative intervention may be required and survival is not assured. The incidence of acute pancreatitis is between 17-28 per 100,000 population. Patients with severe pancreatitis should be identified as early as possible (within 7 days) and managed by a team experienced in preventing and treating its complications.

Symptoms and Diagnosis
Patients often complain of severe upper abdominal pain radiating straight through to the back, with associated nausea and vomiting. Abdominal findings vary from epigastric tenderness on deep palpation to an acute abdomen with distention. Serum amylase and lipase levels are usually elevated, but correlate poorly with disease severity. It is therefore essential to establish the etiology of pancreatitis. In some cases, treatment of a specific cause of pancreatitis is indicated, such as cholecystectomy for patients with gallstone pancreatitis. It may initially be difficult to distinguish severely ill patients from those with mild disease. Early unenhanced CT scan can confirm the diagnosis and serve as a useful indicator of severity. If the patient with severe pancreatitis is adequately resuscitated, a CT scan with oral and IV contrast should be obtained if renal function is adequate. Pancreatic necrosis, estimated on early, contrast-enhanced helical CT is a specific predictor of morbidity and mortality. The presence or absence of cholelithiasis should be determined as early as possible, usually with ultrasonography. Other useful diagnostic tests include arterial blood gases, CBC, and serum chemistries such as calcium, glucose, and creatinine.

Treatment
Patients with mild pancreatitis usually experience resolution of their pain within 24-48 hours after a regimen of no oral intake, narcotics for pain relief, and intravenous fluids. Once oral intake is tolerated, patients can be discharged from the hospital. Patients with pancreatitis secondary to gallstones should undergo cholecystectomy during the same hospitalization. Common bile duct obstruction from a stone at the ampulla requires urgent removal of the stone (preferably by endoscopic papillotomy) if there is evidence of cholangitis. Patients with a history of alcoholism should be counseled and encouraged to participate in a detoxification and rehabilitation program, while patients with hyperlipidemia should be placed on appropriate diet and drug therapy. Severe pancreatitis is often associated with a marked increase in microvascular permeability, leading to large volume losses of intravascular fluid into the tissues, thereby decreasing perfusion of the lungs, kidneys, and other organs. Probably the single most important element in preventing multiple organ failure is vigorous fluid resuscitation with electrolyte solutions in order to optimize cardiac index and maintain hemodynamic stability. Swan-Ganz monitoring is helpful in such patients. In this scenario, fewer patients develop multiple organ failure. Patients with severe pancreatitis should be treated in an intensive care unit because of the associated high mortality and morbidity rates. If these patients do not improve within 7 days referral should be made to a medical center with a team experienced in caring for severe pancreatitis. Nonoperative management is recommended for sterile pancreatic necrosis, while surgical debridement and drainage remains the preferred approach for infected pancreatic necrosis. Repeated scheduled reoperation for necrosectomy until all necrotic tissue has been debrided may be required. When infection supervenes two or more weeks after onset of symptoms, the infected pancreatic and peripancreatic tissue is more readily defined and removed at operation, with a decreased mortality rate. Treatment of infected fluid collections may include endoscopic, radiologic, and operative procedures. Preventing or delaying infection with appropriate antibiotics possibly reduces morbidity and mortality. Aggressive nutritional support is also essential for these patients.

Expected Outcomes
The overall mortality of severe pancreatitis is approximately 15%. The average length of hospital stay for uncomplicated pancreatitis is 5-14 days. The average length of hospital stay for complicated pancreatitis can range as high as 40 to 65 days. These outcomes should improve with adequate early resuscitation and the judicious use of invasive procedures.

Qualifications of Personnel Providing Care or Surgery
These patients should ideally be treated by a team of physicians qualified to care for critically ill patients and especially patients with severe pancreatitis. At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for pancreatitis . Pancreatic surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of pancreatic disease. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the pancreas. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery of the pancreas is important to assess. The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes.

References
Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2003;(4):CD002941.

Beger HG, Bittner R, Block S, Buchler M. Bacterial contamination of pancreatic necrosis. Gastroenterology 1986;91:433-438.

Bradley EL, III. Acute Pancreatitis: Diagnosis and Therapy. New York: Raven Press, 1994.

Broome AH, Eisen GM, Harland RC, et al. Quality of life after treatment for pancreatitis. Ann Surg 1996;223:665-672.

Casas JD, Diaz R, Valderas G, Mariscal A, Cuadras P. Prognostic value of CT in the early assessment of patients with acute pancreatitis. Am J Roentgenol 2004 Mar;182(3):569-74.

Luiten EJT, Hop WOJ, Lange JF, Bruining HA. Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 1995;222:57-65.

Ranson JHC. Acute pancreatitis. In: Surgical Disease of the Biliary Tract and Pancreas (Braash JW and Tompkins RK, eds). St. Louis: Mosby Year Book Inc., 1994:432-472

Written 3/11/96
Revised 5-4-96
Revised 9-26-96
Revised 10-7-96
Board Approved 10/8/96
Revised 2-5-97
Revised 5-5-97
Revised 5-11-97
Revised 9/26/99
Revised 10/25/99
Proofed 1/8/00
Revised 5/15/04

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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