Initial management of a patient with<unk>  consists of supportive care with fluid resuscitation, pain control, nothing by mouth, and nutritional support. Fluid replacement Aggressive hydration at a rate of 5 to 10 mL/kg per hour of isotonic crystalloid solution (e.g., normal saline or lactated Ringer's solution) to all patients with<unk> , unless cardiovascular, renal, or other related comorbid factors preclude aggressive fluid replacement. In patients with severe volume depletion that manifests as hypotension and tachycardia, more rapid repletion with 20 mL/kg of intravenous fluid given over 30 minutes followed by 3 mL/kg/hour for 8 to 12 hours. Fluid requirements should be reassessed at frequent intervals in the first six hours of admission and for the next 24 to 48 hours. The rate of fluid resuscitation should be adjusted based on clinical assessment, hematocrit and blood urea nitrogen (BUN) values. In the initial stages (within the first 12 to 24 hours) of<unk> , fluid replacement has been associated with a reduction in morbidity and mortality. Pain control Abdominal pain is often the predominant symptom in patients with<unk>  and should be treated with analgesics. Opioids are safe and effective at providing pain control in patients with<unk> . Adequate pain control requires the use of intravenous opiates, usually in the form of a patient-controlled analgesia pump. Hydromorphone or fentanyl (intravenous) may be used for pain relief in<unk> . Fentanyl is being increasingly used due to its better safety profile, especially in renal impairment. As with other opiates, fentanyl can depress respiratory function. It can be given both as a bolus as well as constant infusion. Meperidine has been historically favored over morphine because of the belief that morphine caused an increase in sphincter of Oddi pressure. However, no clinical studies suggest that morphine can aggravate or cause<unk>  or cholecystitis. In addition, meperidine has a short half-life and repeated doses can lead to accumulation of the metabolite normeperidine, which causes neuromuscular side effects and, rarely, seizures. Bowel rest In the management of<unk> , the treatment is to stop feeding the patient, giving them nothing by mouth, giving intravenous fluids to prevent dehydration, and sufficient pain control. As the pancreas is stimulated to secrete enzymes by the presence of food in the stomach, having no food pass through the system allows the pancreas to rest.<unk> proximately 20% of patients have a relapse of pain during<unk> .<unk> proximately 75% of relapses occur within 48 hours of oral refeeding. The incidence of relapse after oral refeeding may be reduced by post-pyloric enteral rather than parenteral feeding prior to oral refeeding. IMRIE scoring is also useful. Nutritional support Recently, there has been a shift in the management paradigm from TPN (total parenteral nutrition) to early, post-pyloric enteral feeding (in which a feeding tube is endoscopically or radiographically introduced to the third portion of the duodenum). The advantage of enteral feeding is that it is more physiological, prevents gut mucosal atrophy, and is free from the side effects of TPN (such as fungemia). The additional advantages of post-pyloric feeding are the inverse relationship of pancreatic exocrine secretions and distance of nutrient delivery from the pylorus, as well as reduced risk of aspiration. Disadvantages of a naso-enteric feeding tube include increased risk of sinusitis (especially if the tube remains in place greater than two weeks) and a still-present risk of accidentally intubating the trachea even in intubated patients (contrary to popular belief, the endotracheal tube cuff alone is not always sufficient to prevent NG tube entry into the trachea). Oxygen Oxygen may be provided in some patients (about 30%) if Pao2 levels fall below 70mm of Hg. Antibiotics Up to 20 percent of people with<unk>  develop an infection outside the pancreas such as bloodstream infections, pneumonia, or urinary tract infections. These infections are associated with an increase in mortality. When an infection is suspected, antibiotics should be started while the source of the infection is being determined. However, if cultures are negative and no source of infection is identified, antibiotics should be discontinued. Preventative antibiotics are not recommended in people with<unk> , regardless of the type (interstitial or necrotizing) or disease severity (mild, moderately severe, or severe) ERCP In 30% of those with<unk> , no cause is identified. ERCP with empirical biliary sphincterotomy has an equal chance of causing complications and treating the underlying cause, therefore, is not recommended for treating<unk> . If a gallstone is detected, Endoscopic retrograde cholangiopancreatography (ERCP), performed within 24 to 72 hours of presentation with successful removal of the stone, is known to reduce morbidity and mortality. The indications for early ERCP are: * Clinical deterioration or lack of improvement after 24 hours * Detection of common bile duct stones or dilated intrahepatic or extrahepatic ducts on abdominal CT The risks of ERCP are that it may worsen<unk> , it may introduce an infection to otherwise sterile<unk> , and bleeding. Surgery Surgery is indicated for (i) infected pancreatic necrosis and (ii) diagnostic uncertainty and (iii) complications. The most common cause of death in<unk>  is secondary infection. Infection is diagnosed based on 2 criteria *Gas bubbles on CT scan (present in 20 to 50% of infected necrosis) *Positive bacterial culture on FNA (fine needle aspiration, usually CT or US guided) of the pancreas. Surgical options for infected necrosis include: *Minimally invasive management – necrosectomy through small incision in skin (left flank) or abdomen *Conventional management – necrosectomy with simple drainage *Closed management – necrosectomy with closed continuous postoperative lavage *Open management – necrosectomy with planned staged reoperations at definite intervals (up to 20+ reoperations in some cases) Other measures *Pancreatic enzyme inhibitors are proven not to work. *The use of octreotide has been shown not to improve outcomes.
Acute pancreatitis
Grey Turner's sign
Gallstone ileus
Chronic pancreatitis
Acute abdomen
Pancreatic abscess
Ascending cholangitis
Pancreatic fistula