Management of Severe Acute Pancreatitis

Abstract

Purpose of review: There have been significant advancements in different aspects of management of severe acute pancreatitis (SAP). Our review of the most recent literature focuses on severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention for SAP and its extra-pancreatic complications.

Recent findings: Recent studies on serum cytokines for the prediction of SAP have shown superior prognostic performance when compared with conventional laboratory tests and clinical scoring systems. In patients with established SAP and vascular leak syndrome, intravenous fluids should be administered with caution to prevent intra-abdominal hypertension and volume overload. Endoscopic retrograde cholangiopancreatography improves outcomes only in AP patients with suspected cholangitis. Early enteral tube-feeding does not appear to be superior to on-demand oral feeding. Abdominal compartment syndrome is a highly lethal complication of SAP that requires percutaneous drainage or decompressive laparotomy. Endoscopic transmural drainage followed by necrosectomy (i.e., "step-up approach") is the treatment strategy of choice in patients with symptomatic or infected walled-off pancreatic necrosis.

Summary: SAP is a complex clinical syndrome associated with a high mortality rate. Early prediction of SAP remains challenging due to the limited accuracy of the available prediction tools. Early fluid resuscitation, organ support, enteral nutrition, and prevention of/or prompt recognition of abdominal compartment syndrome remain cornerstones of its management. A step-up, minimally invasive drainage/debridement is the preferred approach for patients with infected pancreatic necrosis.

Keywords: Inflammatory cytokines; Necrotizing pancreatitis; Organ failure; Severe pancreatitis.

Fig. 1

Management algorithm of severe acute pancreatitis according to separate domains. UO, urine output; MAP, mean arterial pressure; BUN, blood urea nitrogen; IAP, intra-abdominal pressure; ICU, intensive care unit; PCD, percutaneous drainage. ⁺Nasojejunal route in patients with gastric or duodenal obstruction; ⁺⁺presence of necrosis is best established with a contrast-enhanced cross-sectional imaging; ^#signs of infected necrosis include gas within a necrotic collection, or worsening organ failure in a patient with necrotic collection despite maximum medical therapy in the intensive care unit, or new onset fevers in patients with established necrotic collection; *endoscopic step-up intervention: endoscopic ultrasound guided transmural drainage, followed by endoscopic necrosectomy if there is no clinical improvement in 72 h; **in hypotensive SAP patients who are not fluid responsive, intensive care unit admission needs to be considered to prevent volume overload; ***decompressive measures include decompressive laparotomy or percutaneous drain placement.