Severe acute pancreatitis: how to treat?

The article was professionally consulted by a doctor of Gastrointestinal Endoscopy - Department of Medical Examination & Internal Medicine - Vinmec Danang International General Hospital.

Severe acute pancreatitis is an acute, rapidly progressive medical disease that causes multi-organ failure and is life-threatening if not treated promptly. Accordingly, this diagnosis requires early detection and active medical and surgical intervention, requiring the participation of a team of professional and experienced doctors as well as adequate means, equipment and machinery to support aid.
The treatment process for severe acute pancreatitis includes the following basic components in parallel:

This is the first approach to treatment in all patients even when acute pancreatitis is only a suspected diagnosis. Because this disease will trigger a rapid systemic inflammatory response, it is essential to control the daily circulating volume from the beginning.
The patient will be pre-booked from two intravenous lines on two different extremities, ready to access the circulation at any time. The type of infusion is Lactate Ringer which will be preferred over physiological saline. The reason is that many observations show that this fluid has a better ability to reduce the systemic inflammatory response syndrome, only not in cases of acute pancreatitis due to hypercalcemia (because Lactate Ringer contains a higher concentration of calcium than water). physiological salt).
The volume of infusion should be 250-500 ml per hour for the first 12-24 hours depending on cardiovascular status. The following days still need to be infused with a minimum of 2 liters per day. At the same time, the doctor should pay attention to adding potassium according to the results of the ionogram.
Adequate fluid rehydration to help ensure circulating volume, urine output, avoid too concentrated blood causing kidney failure as well as cardiovascular collapse and cardiac arrest.

Abdominal pain in acute pancreatitis is classified as a relatively severe pain. Because pancreatic enzymes, when released from the duct, will become toxic, capable of "digesting" the abdominal organs that it comes into contact with.
Therefore, patients with acute pancreatitis are often hospitalized with sudden severe upper abdominal pain, spreading to the back, making the patient extremely struggling. Therefore, pain control is also a goal in the treatment of acute pancreatitis.
Common pain relievers are rarely chosen. Instead, doctors will choose a centrally acting pain reliever with properties similar to morphine but with stronger effects and shorter duration of action than morphine, such as pethidine (Meperidine) at a dose of 50mg injectable. intramuscularly or intravenously every 6 to 8 hours.

Besides taking pain relievers, taking drugs to reduce pancreatic secretion also helps relieve pain for patients. When the amount of pancreatic juice released is less, the organs will be less damaged.
The drug of choice is octreotide. This is a synthetic substance that mimics the body's natural pharmacological effects of somatostatin, which inhibits the secretion of enzymes by the digestive organs in general, including the stomach and small intestine, not just the pancreas. Because the drug has a long effect, it only needs to be injected under the skin 3 times a day and only needs to be used in the first days, stopping when the patient's pain is relieved, the level of inflammation has improved.

When the viscera are damaged due to the massive release of pancreatic enzymes into the abdominal cavity, their physiological activity will stagnate. The intestinal loops lose the ability to peristalsis, becoming paralytic, causing patients to have abdominal pain, bloating, nausea and vomiting for a long time. Therefore, all patients with severe acute pancreatitis need to stop eating by mouth and insert a catheter from the nose into the stomach.
By this catheter, the secretions in the gastrointestinal tract that cannot be absorbed will lead out, reducing the patient's distention; at the same time avoid the possibility of aspiration into the respiratory tract due to vomiting.
During the first days, the patient was fed intravenously. Over the next week, when the severe acute pancreatitis was well controlled, the degree of abdominal pain gradually decreased without the use of analgesics, the patient's nausea and vomiting decreased, the feeling of hunger returned, and the bowel sounds were heard. then the catheter may be removed and reintroduced orally.
Food types in order are sugar water - sugar porridge - rice paste - plain rice with a conversion rate and increasing quantity as the patient tolerates it. In addition, in the first month, it is necessary to limit fat so that the pancreas can fully recover.

Because the intra-abdominal organs are damaged by exposure to pancreatic enzymes, the risk of infection is great. The number of bacteria residing in the intestinal tract is very large, ready to invade and cause disease when organs lose their integrity, causing local and general peritonitis. Then, the infection - intoxication spreads throughout the body, the patient falls into septic shock, which is life-threatening.
Therefore, in cases of severe acute pancreatitis, antibiotics are always considered as soon as possible. The antibiotic chosen must have high bioavailability, broad spectrum, strong activity, high dose with systemic route from the beginning. The duration of antibiotics can be extended up to three weeks.
After the first week, if the patient has been treated with antibiotics but the patient still has a fever and signs of infection, imaging shows that there are abscesses in the peritoneum, it is necessary to intervene early percutaneous aspiration to protect the patient. pus production and culture, choose the appropriate antibiotic.

Liver and kidney damage, respiratory and circulatory problems as well as multi-organ failure are complications of severe acute pancreatitis. Therefore, patients need to be actively monitored and early detection of complications for timely intervention.
The parameters to monitor are pulse, blood pressure, temperature, urine output, blood oxygen saturation several times a day. At the same time, blood count tests, liver function, kidney function, electrolytes... are also repeated daily.

When the level of acute pancreatitis is severe, triggering the "waterfall" of an inflammatory response, intermediate chemical products are released massively into the blood to become toxic substances, causing damage to organs. Moreover, the multi-organ failure also makes the toxins accumulate in the blood more heavily.
In these situations, the evaluation of pancreatitis is difficult to control but the toxic concentration is constantly increasing, potentially life-threatening, the patient should be considered for dialysis to remove the toxin. In addition, if the patient has acute pancreatitis due to hypertriglyceridemia with a triglyceride level above 1000 mg/dL, an emergency plasmapheresis is indicated.
At facilities with adequate facilities, the majority of patients who receive timely dialysis interventions when properly indicated will have a very positive prognosis, right from the first dialysis.

In the case of acute gallstone pancreatitis, the patient should undergo endoscopic retrograde cholangitis to remove stones within the first 72 hours if stones are found in the common bile duct or within 24 to 48 hours if cholangitis is present. If acute pancreatitis is caused by gallstones or gallbladder sludge, the patient may be considered for cholecystectomy within 7 days of recovery to help reduce the risk of recurrent acute pancreatitis.
In addition, indications for surgical intervention also need to be set when the patient has complications of large pancreatic pseudocyst, causing pain or compression of nearby organs, infected pancreatic pseudocyst, bleeding in the cyst, ruptured Pancreatic pseudocyst, severe necrotizing pancreatitis or associated infection, pancreatic abscess.
In summary, the treatment of severe acute pancreatitis needs to be carried out actively, applying the means and equipment and sometimes having to coordinate with many specialties such as intensive care, general surgery from the very beginning. At the same time, close monitoring, early detection and good control of complications are required to improve the patient's prognosis.
Pancreatitis is a dangerous disease that cannot be underestimated, for serious patients, it is necessary to closely monitor the disease status, and continue dialysis to maintain a positive prognosis. In addition, patients need to monitor their general health periodically to detect complications and treat them early to avoid affecting the severity of pancreatitis.
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