In Focus

New concepts in the management of acute pancreatitis


 

Introduction

Acute pancreatitis (AP) is a major clinical and financial burden in the United States. Several major clinical guidelines provide evidence-based recommendations for the clinical management decisions in AP, including those from the American College of Gastroenterology (ACG; 2013),1 and the International Association of Pancreatology (IAP; 2013).2 More recently, the American Gastroenterological Association (AGA) released their own set of guidelines.3,4 In this update on AP, we review these guidelines and reference recent literature focused on epidemiology, risk factors, etiology, diagnosis, risk stratification, and recent advances in the early medical management of AP. Regarding the latter, we review six treatment interventions (pain management, intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis) and four preventive interventions (alcohol and smoking cessation, same-admission cholecystectomy for acute biliary pancreatitis, and chemoprevention and fluid administration for post-ERCP pancreatitis [PEP]). Updates on multidisciplinary management of (infected) pancreatic necrosis is beyond the scope of this review. Table 1 summarizes the concepts discussed in this article.

Recent advances in AP epidemiology, evaluation, and management

Recent advances in epidemiology and evaluation of AP

Epidemiology

AP is the third most common cause of gastrointestinal-related hospitalizations and fourth most common cause of readmission in 2014.5 Recent epidemiologic studies show conflicting trends for the incidence of AP, both increasing6 and decreasing,7 likely attributable to significant differences in study designs. Importantly, multiple studies have demonstrated that hospital length of stay, costs, and mortality have declined since 2009.6,8-10

Dr. Amar Mandalia is a fellow, gastroenterology, department of internal medicine, division of gastroenterology at Michigan Medicine Ann Arbor

Dr. Amar Mandalia

Persistent organ failure (POF), defined as organ failure lasting more than 48 hours, is the major cause of death in AP. POF, if only a single organ during AP, is associated with 27%-36% mortality; if it is multiorgan, it is associated with 47% mortality.1,11 Other factors associated with increased hospital mortality include infected pancreatic necrosis,12-14 diabetes mellitus,15 hospital-acquired infection,16 advanced age (70 years and older),17 and obesity.18 Predictive factors of 1-year mortality include readmission within 30 days, higher Charlson Comorbidity Index, and longer hospitalization.19

Risk factors

We briefly highlight recent insights into risk factors for AP (Table 1) and refer to a recent review for further discussion.20 Current and former tobacco use are independent risk factors for AP.21 The dose-response relationship of alcohol to the risk of pancreatitis is complex,22 but five standard drinks per day for 5 years is a commonly used cut-off.1,23 New evidence suggests that the relationship between the dose of alcohol and risk of AP differs by sex, linearly in men but nonlinearly (J-shaped) in women.24 Risk of AP in women was decreased with alcohol consumption of up to 40 g/day (one standard drink contains 14 g of alcohol) and increased above this amount. Cannabis is a possible risk factor for toxin-induced AP and abstinence appears to abolish risk of recurrent attacks.25

Pages

Next Article: