Lecture on the treatment of acute pancreatitis

2021-08-10 12:29 PM

As a progressive disease, there is always necrosis of pancreatic tissue, necrotic pancreatic tissue can become infected. The prognosis is very poor. Moreover, the production of Cytokines synergizes

Preamble

Acute pancreatitis is an acute, highly dynamic inflammatory process of the pancreas, with diverse involvement of other adjacent tissues or distant organ systems. The differential diagnosis of severe or mild form is made early to have an appropriate treatment plan.

Severe acute pancreatitis is an important clinical condition with a high mortality rate due to severe systemic and local complications.

Clinical form

Mild and moderate acute pancreatitis

This form of the disease accounts for most 70-80% of cases of acute pancreatitis. Patients only need short hospitalization from 3-7 days with supportive medical treatment.

Severe acute pancreatitis

Account for 20 - 30% in acute pancreatitis.

As a progressive disease, there is always necrosis of pancreatic tissue, necrotic pancreatic tissue can become infected. The prognosis is very poor. In addition, the production of cytokines associated with severe pancreatitis can lead to the risk of pancreatic failure.

Clinical picture: Multiple organ failure, very difficult to treat. High mortality rate 70-90%

Often a combination of multiple therapies is required for treatment. Patients must be hospitalized in the ICU or must be in intensive care, monitoring vital signs every 2 - 4 hours.

Systemic complications are the main cause of death in severe acute pancreatitis (30-40%).

Organ failure

Mortality rate

Shock

40%

Respiratory failure

60%

CKD

80%

Multiple organ failure (4 organs)

90%

Treatment

General principles

Coordination of internal and external treatment:

70-80% of acute pancreatitis resolves spontaneously and spontaneously with medical treatment, usually 5-7 days from the start of treatment.

20-30% have serious complications requiring surgical intervention.

Let the pancreas rest.

Supportive treatment; prevention and treatment of complications.

Internally medical treatment

Medical treatment applies to mild acute pancreatitis, even in severe acute pancreatitis after surgical treatment.

Pain relief:

Meperidine (Dolargan):

50 -100mg every 4-6 hours IM, IV.

Tiemodium methylsulfate (Visceralgine):

5mg X 3 IV.

Noramidopyrine (Novalgine):

500mg X 3 IV, IM.

Note: Avoid using Morphine because it causes spasms of the sphincter of Oddi, worsening the obstruction. Its derivatives can be used, but peritonitis should be excluded.

Decreased pancreatic secretion:

Metoclopramide (Primperan):

10 - 20 mg X 2-3 times IM, IV.

Place a nasogastric tube - suction:

Helps reduce the release of Gastrin from the stomach and prevents gastric contents (mainly HCL) into the duodenum, thereby reducing stimulation of pancreatic secretion; At the same time, it relieves stomach tension and prevents vomiting.

Insertion of a dd catheter is not necessary for mild cases.

The group of drugs that inhibit acid secretion:

Clinical studies have shown that the use of acid-suppressing drugs such as Histamine-2 Blockers is not clearly effective in acute pancreatitis. Its role is probably the prevention of gastrointestinal bleeding due to stress.

Octreotide (or Somatostatin):

It is most effective in the treatment of acute pancreatitis at present because it inhibits the secretion of basal and stimulated pancreatic juice. At the same time, it also stimulates the activity of the reticuloendothelial system and regulates the number of cytokines. 

Dosage: 100 m/ 8 hours by slow intravenous injection or subcutaneous injection.

Feeding:

Fasting for the first few days, parenteral feeding.

Ensure enough calories/day with solutions:

Superior road.

Protein.

Lipid solution.

Feed again by mouth when the patient's abdominal pain, vomiting, and pancreatic enzymes decrease. The first day or two, give sugar water and sugar porridge (half solid, half loose); then eat soft foods that are easy to digest for the next 3 days and finally eat solid foods such as: sticky rice then plain rice with little fish meat but no fat, avoid milk. If symptoms recur, continue to stop eating by mouth; Pain when eating again occurs in about 20% of cases.

Prevention and treatment of shock:

Guaranteed circulating volume:

Infusion of fluids and colloidal solutions to maintain circulating volume. If shock occurs, the cause should be evaluated:

Hemorrhagic shock: Blood transfusion.

Septic shock: Use appropriate antibiotics.

Toxic shock: Fluids and vasopressors.

Intravenous dose dopamine 2-5  mg / kg / min dose increased gradually up to 20 mg / kg / min to maintain maximum BP 90 mmHg.

Or: Norepinephrine diluted in 1000ml 4mg intravenous solution 3-5ml / min (4 mg <15 mg / min).

Central venous pressure (CVP): to monitor fluid replacement.

The effectiveness of Kallicrein inhibitors (Trasylon) is not clear

Other treatments:

Patients may require dialysis if there is a renal failure or acute tubular necrosis. However, this rarely happens. 

Complications need to be detected and treated:

Respiratory failure: Oxygen, respiratory support.

Functional renal failure: Fluid rehydration, diuretic, dialysis.

Coagulation disorders: Heparin 5000 - 8000 units /8 hours, monitor TS, TC.

Antibiotic:

The use of antibiotics in the treatment of acute pancreatitis has 2 schools:

In the past, antibiotics were used in acute pancreatitis in the presence of an infection.

Today, severe acute pancreatitis requires antibiotics in the first place because the infection is the leading cause of death in severe acute pancreatitis, estimated at 80%.

It is recommended to use antibiotics with good diffusibility in necrotic pancreatic tissue such as: Ofloxacin, Metronidazole, Mezlo-cillin. Imipenem. Ampicillin is not effective in these patients.

Indications for surgery

There are surgical complications: hemorrhagic necrotizing pancreatitis, peritonitis, pancreatic abscess.

For the treatment of combined gallstones: Endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy with early stone removal (within the first 72 hours).

When there is active medical treatment (for 3 days) but the disease does not improve.

There is doubt in the diagnosis (referring to another surgical illness).

Prognosis

70 - 80% of the patients had a mild and favorable condition, and they were discharged from the hospital after 5-7 days of treatment.

20 - 30% progress to severe complications and these complications are easily fatal.

When receiving the disease, it is necessary to evaluate the severity or lightness to have the appropriate treatment attitude.

Prognosis is based on many factors

Clinically based:

Severe cases:

Hemorrhage: Bruising, vomiting blood.

Shock: On entry or later development.

Peritonitis.

Respiratory failure.

Relatively severe prognostic cases:

> 55 years old.

Intestinal obstruction (paralytic ileus).

Abdominal pain persists after medical treatment.

Based on Ranson index

There are 11 elements. If any element is present give 1 point.

At the time of admission:

Age > 55.

BC > 16000/mm3.

Glycemie > 200mg / dl.

LDH 1,5 times   (> 350UI / l).

SGOT (ASAT): >6 times normal (>250UI/l).

In 48 hours:

Hyperuremia: > 16mmol/l.

PaO2 < 60 mmHg.

Calcemie < 8mg / dl.

Hct decreased by more than 10% compared to the original.

Bicarbonate: Less than 4mEq/l.

Tissue drainage > 6 liters.

Above the 3 criteria, the prognosis is severe.