Approximately 80% of patients admitted with acute pancreatitis have mild, self-limited disease and are discharged within several days. Mortality associated with acute pancreatitis has decreased over time, and the overall mortality is now approximately 2%. A new Review Article summarizes recent changes in the management of acute pancreatitis, encompassing fluid resuscitation, antibiotic use, nutritional support, and treatment of necrosis, and also addresses common misunderstandings and areas of controversy.
• What are some of the factors that might contribute to unexplained pancreatitis?
The cause of acute pancreatitis often cannot be established, and the proportion of persons who are considered to have idiopathic acute pancreatitis increases with age. A number of potential factors might contribute to unexplained pancreatitis, including unidentified genetic polymorphisms, exposure to smoking and other environmental toxins, and effects of coexisting diseases that are commonly associated with acute pancreatitis (e.g., obesity and diabetes).
• What is the role of prophylactic antibiotics in acute pancreatitis?
Although the development of infected pancreatic necrosis confers a significant risk of death, well-designed trials and meta-analyses have shown no benefit of prophylactic antibiotics. Prophylaxis with antibiotic therapy is not recommended for any type of acute pancreatitis unless infection is suspected or has been confirmed.
Morning Report Questions
Q: Should patients with acute pancreatitis receive enteral or parenteral nutrition?
A: Total parenteral nutrition is now known to be more expensive, riskier, and no more effective than enteral nutrition in patients with acute pancreatitis. In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started. A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods. Most patients with mild acute pancreatitis can be started on a low-fat diet soon after admission, in the absence of severe pain, nausea, vomiting, and ileus (all of which are unusual in mild cases of acute pancreatitis). A need for artificial enteral feeding may be predicted by day 5, on the basis of symptoms that continue to be severe or an inability to tolerate attempts at oral feeding. Although nasojejunal tube feeding is best for minimizing pancreatic secretion, randomized trials and a meta-analysis have shown that nasogastric or nasoduodenal feeding is clinically equivalent. Total parenteral nutrition should be reserved for the rare cases in which enteral nutrition is not tolerated or nutritional goals are not met. Unfortunately, total parenteral nutrition continues to be used frequently in patients with acute pancreatitis.
Q: What is the risk of recurrent gallstone pancreatitis if cholecystectomy is delayed?
A: Cholecystectomy prevents recurrent gallstone pancreatitis. A delay of cholecystectomy for more than a few weeks places the patient at a high (up to 30%) risk for relapse. Cholecystectomy performed during the initial hospitalization for mild pancreatitis due to gallstones reduces the rate of subsequent gallstone-related complications by almost 75%, as compared with cholecystectomy performed 25 to 30 days after discharge. For patients with severe or necrotizing pancreatitis, cholecystectomy may be delayed in order to address other clinically significant conditions or provide time for the pancreatic inflammation to diminish, allowing for better operative exposure.