Diagnosis and management of acute pancreatitis.

OBJECTIVE: To review the diagnosis and management of patients with acute pancreatitis. DATA SOURCES: A review of articles reporting on the diagnosis and management of acute pancreatitis. SUMMARY OF REVIEW: Acute pancreatitis is an acute inflammatory disorder of the pancreas caused by an intracellular activation of pancreatic digestive enzymes. The destruction of pancreatic parenchyma induces a systemic activation of coagulation, kinin, complement and fibrinolytic cascades with liberation of cytokines and reactive oxygen metabolites which, if severe and overwhelming, can lead to shock, acute renal failure and the acute respiratory distress syndrome. In approximately 45% of cases the disorder is associated with cholelithiasis, with ethanol abuse accounting for a further 35% of patients. In 10% of patients no cause may be found. In 85-90% of patients, acute pancreatitis is self-limiting and subsides spontaneously within 4-7 days. Specific treatment for acute pancreatitis currently does not exist and management is still supportive, with therapy aimed at reducing pancreatic secretion, replacing fluid and electrolytes losses and analgesia. All patients with severe acute pancreatitis who have one (or more) organ failures (e.g. circulatory, pulmonary or renal) should be managed in an intensive care unit with mechanical ventilation, inotropic agents and renal replacement therapy being used to manage organ failure. In selected circumstances, endoscopic retrograde cholangiopancreatography (ERCP), antibiotics and surgical drainage are used. For example, ERCP will reduce morbidity in patients with ampullary or common bile duct stones associated with acute pancreatitis, if obstructive jaundice or cholangitis are present. Prophylactic antibiotics (e.g. imipenem 500 mg i.v. 8-hourly for 7-10 days with fluconazole 400 mg i.v. daily) will reduce the incidence of pancreatic infection in patients with severe acute pancreatitis with pancreatic necrosis, and surgical intervention in severe acute pancreatitis, while rarely used, in patients who have a progressively increasing inflammatory mass and worsening multi-system organ failure, necrosectomy with open or closed drainage may be required.
CONCLUSIONS: Acute pancreatitis is a benign abdominal disorder in up to 85% of cases. In the remaining 10%-15% of cases the disorder is life threatening with management of the disorder requiring admission to an intensive care unit with cardiovascular, respiratory, and renal monitoring and support.