Treatment of severe acute pancreatitis and its complications

Abstract

Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk, a pro-inflammatory response results in systemic inflammatory response syndrome (SIRS). If the SIRS is severe, it can lead to early multisystem organ failure (MOF). After the first 1-2 wk, a transition from a pro-inflammatory response to an anti-inflammatory response occurs; during this transition, the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue, which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However, despite the reduction in overall mortality in the last decade, SAP is still associated with high mortality. In the majority of cases, sterile necrosis should be managed conservatively, whereas in infected necrotizing pancreatitis, the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently, the step-up approach (delay, drain, and debride) may be considered as the reference standard intervention for this disorder.

Keywords: Acute necrotizing pancreatitis; Drainage; Gastrointestinal endoscopy; Infection; Sepsis.

Figure 1

Natural clinical course of severe acute pancreatitis. SIRS: Systemic inflammatory response syndrome; MOF: Multisystem organ failure.

Figure 2

Three catheters inserted percutaneously into the abscess collections formed during the clinical course of necrotizing pancreatitis.

Figure 3

Ultrasound appearance of pancreatic necroses and a large acute fluid collection before and after drainage. A: Large fluid collection and pancreatic necroses before drainage; B: Catheter in the peripancreatic fluid collection; C: Massive pancreatic necroses with secondary fluid collection.

Figure 4

Ultrasound appearance of infected pancreatic necrosis before and after the treatment of acute pancreatitis. A: Infected pancreatic necrosis (IPN) involved the entire pancreas in the beginning of the disease; B: Liquefied areas in the IPN marked by arrows; C: Small necroses and liquid collections around the pancreas 2 mo after the beginning of treatment marked by arrows; D: Normal appearance of the pancreas 6 mo after the beginning of treatment.

Figure 5

Computed tomography. A: Computed tomography (CT) appearance of the infected pancreatic necrosis, which involves the entire pancreas (marked by an arrow); B: CT appearance of a large pancreatic walled-off necrosis in the tail of the pancreas (marked by arrows).