Treatment

Treatment

1. Relieving pain is the first step in treating chronic pancreatitis.
2. The next step is to plan a diet that is high in carbohydrates and low in fat.
3. A doctor may prescribe pancreatic enzymes to take with meals if the pancreas does not secrete enough of its own. The enzymes should be taken with every meal to help the body digest food and regain some weight.
4. In some cases, surgery is needed to relieve pain. The surgery may involve draining an enlarged pancreatic duct or removing part of the pancreas.
5. For fewer and milder attacks, people with pancreatitis must stop drinking alcohol, if they do drink, stop smoking tobacco, if they do smoke, stick to their prescribed diet, and take the proper medications.
6. Sometimes insulin or other drugs are needed to control blood glucose.
7. Complications will be treated if or as they arise (infections, pseudocysts, abscess, respiratory problems, shock, bleeding, malnutritian, weight loss, diabetes, drug dependency, pancreatic cancer.)

Emergency Department Care: Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment:

• Fluid resuscitation:
• Monitor accurate intake/output and electrolyte balance of the patient.
  Crystalloids are used, but other infusions, such as packed red blood cells
  (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis.
• Central lines and Swan-Ganz catheters are used in patients
  with severe fluid loss and very low blood pressure.
• NPO: Patients should have nothing by mouth, and a nasogastric tube should be inserted to assure an empty stomach and to keep the GI system at rest.
• **Begin parenteral nutrition if the prognosis is poor and if the patient is going to be kept in the hospital for more than 4 days.
• Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi.
• Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved.
• Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third generation cephalosporins.
• Continuous oxygen saturation should be monitored by pulse oximetry and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed.
• Perform CT-guided aspiration of necrotic areas, if necessary.
• An ERCP may be indicated for common duct stone removal.
• Consultations: Consult a general surgeon in the following cases:
• For phlegmon of the pancreas, surgery can achieve drainage of any abscess or
  scooping of necrotic pancreatic tissue. It should be followed by postoperative
  lavage of the pancreatic bed.
  In patients with hemorrhagic pancreatitis, surgery is indicated to achieve
  hemostasis, particularly because major vessels may be eroded in acute
  pancreatitis.
• Patients who fail to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room. Surgery in these cases may lead to a better outcome or confirm a different diagnosis.
  In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction. A cholecystectomy may be performed to clear the system from any source of biliary stones.
• Further Inpatient Care:
  
• Transfer patients with Ranson scores of 0-2 to a hospital floor.
• Transfer patients with Ranson scores 3-5 to an intensive care unit.
• Transfer patients with Ranson scores higher than 5 to an intensive care unit with emergency surgery as a possibility.
• Two other systems, the
  

  Acute Physiology and Chronic Health Evaluation (APACHE) and

  the Multiple Organ System Score (MOSS), have been used recently, but these are used more in an ICU setting.

• Further Outpatient Care:
  The patient should be followed routinely with physical examination and amylase
  and lipase assays.

**A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition.

http://www.ncbi.nlm.nih.gov/
posted by nicola 22 hours ago view profile
Dig Surg. 2006;23(5-6):336-44; discussion 344-5.
Petrov MS, Kukosh MV, Emelyanov NV.
Discuss category: Other (Clinical) tags: APACHE Abscess Acute Disease Adult Aged Analysis of Variance C-Reactive Protein Enteral Nutrition Female Humans Infection Male Middle Aged Necrosis Pancreatitis Parenteral Nutrition Prognosis Treatment Outcome all


BACKGROUND: Infectious complications are the main cause of late death in patients with acute pancreatitis. Routine prophylactic antibiotic use following a severe attack has been proposed but remains controversial. On the other hand, nutritional support has recently yielded promising clinical results. The aim of study was to compare enteral vs. parenteral feeding for prevention of infectious complications in patients with predicted severe acute pancreatitis. METHODS: We screened 466 consecutive patients with acute pancreatitis. A total of 70 patients with objectively graded severe acute pancreatitis were randomly allocated to receive either total enteral nutrition (TEN) or total parenteral nutrition (TPN), within 72 h of onset of symptoms. Baseline characteristics were well matched in the two groups. RESULTS: The incidence of pancreatic infectious complications (infected pancreatic necrosis, pancreatic abscess) was significantly lower in the enterally fed group (7 vs. 16, p = 0.02). In the TEN group, 7 patients developed multiple organ failure whereas 17 parenterally fed patients developed multiple organ failure (p = 0.02). Overall mortality was 20% with two deaths in the TEN group and twelve in the TPN Prognosis:
Ranson developed a series of different criteria for the severity of acute pancreatitis:

• Present on admission

..........1. Older than 55 years
..........2. WBC higher than 16,000 per mcL
..........3. Blood glucose higher than 200 mg/dL
..........4. Serum lactate dehydrogenase (LDH) more than 350 IU/L
..........5. SGOT (ie, aspartate aminotransferase [AST]) >250

• Developing during the first 48 hours:

..........1. Hematocrit fall more than 10%
..........2. BUN increase more than 8 mg/dL
..........3. Serum calcium less than 8 mg/dL
..........4. Arterial oxygen saturation less than 60 mm Hg
..........5. Base deficit higher than 4 mEq/L
..........6. Estimated fluid sequestration higher than 600 mL

• What the Score Means:

1. A Ranson score of 0-2 has a minimal mortality
....rate Patient to regular floor.

2. A Ranson score of 3-5 has a 10%-20% mortality
.....rate. Patient to ICU
3. A Ranson score higher than 5 has a mortality
.....rate of more than 50% and is associated with
.....more systemic complications. Patient to ICU
.....emergency surgery floor.

Links to Wikipedia for more information:
Pancreas: (Acute pancreatitis, Chronic pancreatitis, Pancreatic pseudocyst,
Hereditary pancreatitis, Pancreatic cancer)

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