Acute pancreatitis
Therapeutic target
- Avoidance of complications
- Adequate pain management
- Healing of the disease
Therapy recommendations
- Admit patients to a hospital as early as possible to avoid complications.
- Risk stratification using the Acute Physiology And Chronic Health Evaluation Score (APACHE II).
- In most patients (85 to 90%), acute pancreatitis is a self-limiting disease (“ending without external influences”) and resolves within three to seven days after initiation of therapy. There is no causal (etiologic) therapy; symptoms are treated primarily:
- Analgesia (pain relief): pain therapy should follow the WHO staging scheme:
- Non-opioid analgesic (e.g., metamizole).
- Low-potency opioid analgesic (e.g., tramadol) + non-opioid analgesic.
- High-potency opioid analgesic (eg, morphine) + non-opioid analgesic; if necessary, also systemic therapy with procaine or bupuvacaine (local anesthetics).
In the initial phase, a parenteral application (“bypassing the intestine”) is required.In severe pain, the installation of a peridural catheter (PDA) should be considered. Note: freedom from pain facilitates mobilization, improves respiratory function and reduces nausea → prevention of thrombosis (vascular disease in which a blood clot (thrombus) forms in a vein) and pneumonia (pneumonia).
- Nutrition
- Oral food and fluid abstinence
- Placement of a feeding tube for recurrent vomiting and/or subileus/ileus (intestinal obstruction).
- Fluid therapy/volume therapy: compensation of fluid and electrolyte losses (fluid substitution with Ringer’s lactate as buffered whole electrolyte solution (VEL)): Rapid and adequate fluid intake are especially important. Volume therapy should be individualized:
- Generous (500-1,500 ml) intravenous fluid administration within the first hours after hospital admission.
- Up to 8 l/24 h in the first three days under CVD control/central venous pressure (8-12 cm).
- Notice. In acute necrotizing pancreatitis, fluid loss may be up to 10 l/d (fluid sequestration)
- Infusion rate: 5-10 ml/kgKG until clinical targets are reached: Heart rate < 120/min, mean arterial pressure (MAP) 65-85 mmHg, urine output > 0.5-1 ml/kgKG and hour, hematocrit (volume fraction of cellular components in total blood volume) 35-44%.
- Nutritional therapy: parenteral nutrition (“bypassing the digestive tract“) to relieve the pancreas: early enteral nutrition (via a nasojejunal tube/nasal tube that extends into the small intestine in severe cases) helps prevent infection and sepsis (blood poisoning).
- Anti-inflammatory therapy (anti-inflammatory therapy): anti-inflammatory drugs (anti-inflammatory drugs), antiproteases, antioxidants and antibodies have not been successful in studies.
- Antibiotic therapy (antibiosis) for: Cholangitis (bile duct inflammation), abscesses (encapsulated pus accumulation), necrosis (death of tissue)/pseudocysts (cyst-like structure), sepsis; prophylactic in severe necrotizing pancreatitis; duration of therapy at least 7-10 days.
- Stress ulcer prophylaxis with proton pump inhibitors (proton pump inhibitors, PPI; acid blockers) in severe course.
- Thromboembolism prophylaxis (preventive measures to prevent thrombosis/blood clots in a blood vessel).
- Hypertriglyceridemia-induced acute pancreatitis: plasma separation or lipid apheresis (therapeutic blood purification procedure).
- Analgesia (pain relief): pain therapy should follow the WHO staging scheme:
- Intensive care monitoring/care for:
- Suspected necrotizing pancreatitis or any patient with severe pancreatitis according to the Atlanta classification
- Fulfillment of SIRS criteria, sequential organ failure assessment (SOFA), or acute physiology and chronic health evaluation score (APACHE II, e.g., > 8)
- Evaluation of acute pancreatitis as severe: see modified Glasgow criteria below (see pancreatitis/sequelae/prognostic factors below).
- Aanwezigheid van specifieke patiëntkenmerken volgens de richtlijnen van het American College of Gastroenterology (ACG) die een verhoogd risico vormen voor een ernstig verloop van acute pancreatitis (zie hieronder Pancreatitis/Subsequent Conditions/Prognostic Factors).
- Zie ook onder “Verdere therapie”.
Chronische pancreatitis
Therapeutisch doel
- Adequate pijnbestrijding
- Vermijding van complicaties
Therapie-aanbevelingen
- De therapie van de acute episode van chronische pancreatitis verschilt niet van die van acute pancreatitis (zie boven)Cave! Door chronische pijn, die vaak resistent is tegen therapie, ontwikkelen veel patiënten analgetica-misbruik (pijnstiller-misbruik) of mogelijk opiaat-afhankelijkheid.
- Analgesie (pijnstilling): pijntherapie volgens het WHO-stappenschema (zie boven ); zo nodig ook CT-geleide blokkade van de plexus coeliacus.
- Exocriene pancreasinsufficiëntie (EPI; ziekte van de pancreas die gepaard gaat met onvoldoende productie van spijsverteringsenzymen):
- Substitutietherapie, d.w.z. enzymvervanging (zie onder Pancreatic Insufficiency/Pharmacotherapy for Exocrine Pancreatic Insufficiency):
- Doel is om ~30.000 I.U. lipase per maaltijd in de twaalfvingerige darm te brengen; gemakkelijk toegediend:
- Aan het begin van elke hoofdmaaltijd: dosis van 25.000 I.U.
- Bij het begin van elk tussendoortje: dosis van 12.500 I.U.
Het succes van de substitutietherapie wordt aangegeven door klinische parameters (steatorroe, gewichtstoename).
- Doel is om ~30.000 I.U. lipase per maaltijd in de twaalfvingerige darm te brengen; gemakkelijk toegediend:
- Substitutietherapie, d.w.z. enzymvervanging (zie onder Pancreatic Insufficiency/Pharmacotherapy for Exocrine Pancreatic Insufficiency):
- Endocriene insufficiëntie van de pancreas (de pancreas produceert minder of geen insuline meer; ongeveer 80% van de patiënten): zie hieronder Therapie van diabetes mellitusNoot: de therapie van diabetes mellitus type 3c omvat ook maatregelen tot wijziging van de levensstijl.
- Tegelijkertijd ondervoeding → therapie met insuline (werkt anabool).
- In geval van lichte hyperglykemie → therapie met metformine (voor zover er geen contra-indicaties zijn)
- Profylactische antibioticatherapie is niet aangewezen
- Zie ook onder “Verdere therapie”.