Critical care of the patient with acute pancreatitis.

Acute pancreatitis is an inflammatory process of the pancreas with variable involvement of regional tissues and remote organs. This review gives a comprehensive overview of the aetiology, pathophysiology, diagnosis and therapy of acute pancreatitis relevant to the intensivist. Recent international guidelines on the management of acute pancreatitis are summarised. Eighty percent of acute pancreatitis episodes are related either to gallstones or to alcohol abuse. Independent of its aetiology, the pathophysiologic hallmark of acute pancreatitis is the premature activation of trypsin, which leads to massive pancreas inflammation, systemic overproduction of pro-inflammatory mediators and ultimately remote organ dysfunction. All guidelines agree that the diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels and/or characteristic findings on computed tomography. Endoscopic retrograde cholangiopancreatography is recommended as a causative therapy in patients with acute cholangitis or a strong suspicion of gallstones. All guidelines underline the importance of vigorous fluid resuscitation and supplemental oxygen therapy and prefer enteral over parenteral nutrition, with the majority favouring the nasojejunal route. In view of lacking scientific evidence, antibiotic prophylaxis to prevent infection of pancreatic necroses is discouraged by most guidelines. Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis. While sterile pancreatic necrosis should be managed conservatively, infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy. Surgical necrosectomy is the traditional approach, but less invasive techniques (retroperitoneal or laparoscopic necrosectomy, computed tomography-guided percutaneous catheter drainage) may be equally effective.