Chris E. Forsmark, MD; Santhi Swaroop Vege, MD; and C. Mel Wilcox, MD
N Engl J Med 2016; 375:1972-1981, November 17, 2016
Abstract available at: http://www.nejm.org/doi/full/10.1056/NEJMra1505202
This interesting review by three noted experts focuses on the most recent practice changes. Noteworthy points are as follows:
- Patients with vague symptoms and minimal amylase/lipase elevation (<3 times the upper limit of normal) should not receive a diagnosis of AP.
- The most useful predictors of severe disease are elevations at admission and during the following 24 to 48 hours of the following: hematocrit (>44%), blood urea nitrogen (>20 mg/dL), creatinine (>1.8 mg/dL), or systemic inflammatory response syndrome (presence of ≥2 of the following signs: temperature <36 or >38 degrees centigrade, pulse >90 beats/minute, respiratory rate >20/minute or arterial carbon dioxide <32 mmHg, and white cell count <4000 or >12,000 per mm3). These patients should be directed to high-intensity nursing units, where they can be closely monitored because they can decompensate quickly.
- Vigorous fluid therapy (lactated Ringer’s may be superior) is most critical in the first 12–24 hours after symptoms begin but is not very useful after 24 hours.
- With mild AP, complete resolution of pain is unnecessary before beginning low-fat, oral solid or soft feeding, which is associated with shorter hospital stays compared with a clear liquid advance plan.
- Whether artificial enteral feeding is needed can be predicted by day five. Nasogastric, nasoduodenal, and nasojejunal approaches have similar results. Early nasoenteric feeding within 24 hours of admission is not superior to assessing feasibility of oral feeding at 72 hours.
- Prophylactic antibiotics are not beneficial for prevention of infected pancreatic necrosis, which is rare in first 2 weeks.
- Efforts for invasive intervention of pancreatic necrosis should be delayed at least four weeks to allow for walling of healthy tissue from necrosis.
- Alcohol remains a strong risk factor for recurrent AP. Abstinence and smoking cessation interventions can markedly reduce recurrence risk.
- Drug-induced pancreatitis accounts for <5% of cases, and the course is typically mild.