Today we talked about management of severe pancreatitis and reviewed some of the evidence informing our practices.
First of all, how do we stratify severity of pancreatitis and why does it matter? It is really important to stratify severity because aggressive intervention for patients more likely to progress to severe pancreatitis can improve mortality.
Revised Atlanta Criteria (for severity of acute pancreatitis):
- Mild – no organ failure or systemic/local complications
- Moderate – no or transient organ failure (<48 hrs) and/or local complications
- Severe – organ failure >48 hrs, complications involving one or more organs
Lots of scoring systems have been devised, including Ranson’s Criteria, CT Severity Index, APACHE II, BISAP. They take into account variables like hemoconcentration (third-spacing in severe disease, studies with mixed findings based on cut-offs used), creatinine (possibly correlated with risk of necrosis), procalcitonin (most rapid acute phase reactant), CRP (most useful at 48 hours, >150 = severe), BUN (>20 at admission associated with increased risk of death). Some logistical considerations of the scoring systems:
- BISAP is easy to clinically implement and comparable to APACHE II in predicting progression to severe disease
- Ranson’s cannot be completed until 48 hours
- APACHE II involves several clinical and lab data points that are not routinely obtained for all patients
- CT Severity Index requires imaging, which is not always indicated
Overall, the American College of Gastroenterology recommends incorporating several clinical and laboratory parameters into an overall assessment of severity without relying on any particular scoring framework.
Best results have been seen with aggressive fluid resuscitation in the first 12-24 hours. Lactated Ringers has been shown to be associated with lower incidence of SIRS at 24 hours than normal saline, with a theorized mechanism involving the development of metabolic acidosis with NS which potentiates activation of trypsinogen to trypsin (one of the active pancreatic enzymes causing autodigestion and inflammation).
Several studies support early enteral nutrition in severe pancreatitis, as compared with bowel rest and/or total parenteral nutrition. One theory suggests that bowel rest causes mucosal atrophy, which then may increase bowel translocation and risk of infection.
Meta-analyses now suggest that there is no benefit to prophylactic antibiotics in this patient population. Antibiotics are only indicated if there is clinical concern for superinfection (which may be difficult to clinically differentiate from severe pancreatitis!). Antibiotics with good pancreatic penetration include carbapenems, high dose cephalosporins, metronidazole, and fluorquinolones.
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400.
Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008; 57:1698.
Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:710.
Li J-Y, Yu T, Chen G-C, et al. Enteral Nutrition within 48 Hours of Admission Improves Clinical Outcomes of Acute Pancreatitis by Reducing Complications: A Meta-Analysis. Rakonczay Z, ed. PLoS ONE. 2013;8(6):e64926. doi:10.1371/journal.pone.0064926.