Recent advances in understanding and managing acute pancreatitis

Amar Mandalia, Erik-Jan Wamsteker, Matthew J DiMagno, Amar Mandalia, Erik-Jan Wamsteker, Matthew J DiMagno

Abstract

This review highlights advances made in recent years in the diagnosis and management of acute pancreatitis (AP). We focus on epidemiological, clinical, and management aspects of AP. Additionally, we discuss the role of using risk stratification tools to guide clinical decision making. The majority of patients suffer from mild AP, and only a subset develop moderately severe AP, defined as a pancreatic local complication, or severe AP, defined as persistent organ failure. In mild AP, management typically involves diagnostic evaluation and supportive care resulting usually in a short hospital length of stay (LOS). In severe AP, a multidisciplinary approach is warranted to minimize morbidity and mortality over the course of a protracted hospital LOS. Based on evidence from guideline recommendations, we discuss five treatment interventions, including intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis. This review also highlights the importance of preventive interventions to reduce hospital readmission or prevent pancreatitis, including alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis. Our review aims to consolidate guideline recommendations and high-quality studies published in recent years to guide the management of AP and highlight areas in need of research.

Keywords: Acute pancreatitis; alcohol; cannabis; cholecystectomy; ercp; feeding; gallstones; goal directed fluid therapy; smoking.

Conflict of interest statement

Competing interests: MJD received honoraria from the British Medical Journal (for a chapter on chronic pancreatitis published in BMJ Point of Care), Oakstone Publishing for podcasts entitled “Pancreatic Disorders” and “Best of DDW” (Digestive Disease Week), and the American Gastroenterological Association Institute Council for serving as a Clinical Expert Author for the Technical Review on the Initial Medical Management of Acute Pancreatitis, received a consulting fee from Cystic Fibrosis Foundation Therapeutics, Inc. (Bethesda, MD, USA), and serves as Advisory Board Member of the National Pancreas Foundation Michigan Chapter. AM and E-JW declare that they have no competing interests.

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    1. Smeets XJNM, da Costa DW, Fockens P, et al. : Fluid hydration to prevent post-ERCP pancreatitis in average- to high-risk patients receiving prophylactic rectal NSAIDs (FLUYT trial): study protocol for a randomized controlled trial. Trials. 2018;19(1):207. 10.1186/s13063-018-2583-x
    1. Cao WL, Yan WS, Xiang XH, et al. : Prevention effect of allopurinol on post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis of prospective randomized controlled trials. PLoS One. 2014;9(9):e107350. 10.1371/journal.pone.0107350

    2. F1000 Recommendation

    1. Kwanngern K, Tiyapattanaputi P, Wanitpukdeedecha M, et al. : Can a single dose corticosteroid reduce the incidence of post-ERCP pancreatitis? A randomized, prospective control study. J Med Assoc Thai. 2005;88 Suppl 4:S42–5.
    1. Sherman S, Blaut U, Watkins JL, et al. : Does prophylactic administration of corticosteroid reduce the risk and severity of post-ERCP pancreatitis: a randomized, prospective, multicenter study. Gastrointest Endosc. 2003;58(1):23–9. 10.1067/mge.2003.307
    1. Manolakopoulos S, Avgerinos A, Vlachogiannakos J, et al. : Octreotide versus hydrocortisone versus placebo in the prevention of post-ERCP pancreatitis: a multicenter randomized controlled trial. Gastrointest Endosc. 2002;55(4):470–5. 10.1067/mge.2002.122614
    1. Hu J, Li PL, Zhang T, et al. : Role of Somatostatin in Preventing Post-endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis: An Update Meta-analysis. Front Pharmacol. 2016;7:489. 10.3389/fphar.2016.00489

    2. F1000 Recommendation

    1. Li S, Cao G, Chen X, et al. : Low-dose heparin in the prevention of post endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol. 2012;24(5):477–81. 10.1097/MEG.0b013e328351097f
    1. Shao LM, Chen QY, Chen MY, et al. : Nitroglycerin in the prevention of post-ERCP pancreatitis: a meta-analysis. Dig Dis Sci. 2010;55(1):1–7. 10.1007/s10620-008-0709-9
    1. Yuhara H, Ogawa M, Kawaguchi Y, et al. : Pharmacologic prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis: protease inhibitors and NSAIDs in a meta-analysis. J Gastroenterol. 2014;49(3):388–99. 10.1007/s00535-013-0834-x

Source: PubMed

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