Acute Pancreatitis Medication

  • Author: Timothy B Gardner, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Dec 2, 2011
 

Medication Summary

The goal of pharmacotherapy is to relieve pain and minimize complications. Currently, no medications are used to treat acute pancreatitis specifically. Therapy is primarily supportive and involves intravenous (IV) fluid hydration, analgesics, antibiotics (in severe pancreatitis), and treatment of metabolic complications (eg, hyperglycemia and hypocalcemia).

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Analgesics, Other

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and has sedating properties, which are beneficial for patients who have sustained trauma or have painful lesions. Propoxyphene products were withdrawn from the US market on November 19, 2010. The withdrawal was based on new data showing QT prolongation at therapeutic doses. For more information, see the FDA MedWatch safety information.

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Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)

 

Acetaminophen is a peripherally acting drug of choice for mild pain and elevation of body temperature.

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Tramadol (Ultram, Ryzolt, Rybix)

 

Tramadol is a centrally acting analgesic for moderately severe pain. It inhibits ascending pain pathways, altering perception of and response to pain. It also inhibits reuptake of norepinephrine and serotonin.

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Meperidine (Demerol)

 

Meperidine is a synthetic opioid narcotic analgesic for the relief of severe pain. It has multiple actions similar to those of morphine. It may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

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Antibiotics, Other

Class Summary

Antibiotics are used to cover the microorganisms that may grow in biliary pancreatitis and acute necrotizing pancreatitis. The empiric antibiotic regimen is usually based on the premise that enteric anaerobic and aerobic gram-bacilli microorganisms are often the cause of pancreatic infections. Once culture sensitivities are obtained, the antibiotic regimen can be adjusted accordingly.

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Imipenem and cilastatin (Primaxin)

 

Imipenem is a thienamycin derivative with greater potency and broader antimicrobial spectrum than other beta-lactam antibiotics. Cilastatin inhibits dehydropeptidase activity and reduces cilastatin metabolism. Imipenem-cilastatin is used for treatment of multiple-organism infections in which other agents either do not provide wide-spectrum coverage or are contraindicated because of potential toxicity. The 2 agents are generally administered in a 1:1 ratio.

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Ampicillin

 

Ampicillin has bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally.

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Ceftriaxone (Rocephin)

 

Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative activity; it has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

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Contributor Information and Disclosures
Author

Timothy B Gardner, MD  Assistant Professor, Department of Medicine, Dartmouth Medical School; Director of Pancreatic Disorders, Section of Gastroenterology, Dartmouth-Hitchcock Medical Center

Timothy B Gardner, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians-American Society of Internal Medicine, American Gastroenterological Association, American Medical Association, American Pancreatic Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

Brian S Berk, MD  Assistant Professor, Department of Medicine, Dartmouth Medical School; Director of End Stage Liver Disease, Section of Gastroenterology, Dartmouth Hitchcock Medical Center

Brian S Berk, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Gastroenterological Association

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Tushar Patel, MB, ChB Professor of Medicine, Ohio State University Medical Center

Tushar Patel, MB, ChB is a member of the following medical societies: American Association for the Study of Liver Diseases and American Gastroenterological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Noel Williams, MD Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Paul Yakshe, MD Assistant Professor of Medicine, University of Minnesota, Medical Director of Pancreas and Biliary Clinic, Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Fairview University Medical Center

Paul Yakshe, MD is a member of the following medical societies: American College of Gastroenterology, American Pancreatic Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

References

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Suspected acute pancreatitis. Etiologic factors and forms of acute pancreatitis. Ranson criteria.
Mild pancreatitis. Favorable prognostic signs for acute pancreatitis. Medical management and studies used for acute pancreatitis.
Prognostic indicators for severe pancreatitis and ICU management.
Diagnosis and treatment of necrotizing pancreatitis.
Treatment of and studies used for pancreatic pseudocysts.
Idiopathic recurrent pancreatitis. Etiologies for acute pancreatitis.
Pancreatic abscess. Definition of an abscess.
This patient with acute gallstone pancreatitis underwent endoscopic retrograde cholangiopancreatography. Cholangiogram shows no stones in common bile duct and multiple small stones in gallbladder. Pancreatogram shows narrowing of pancreatic duct in area of genu, resulting from extrinsic compression of ductal system by inflammatory changes in pancreas.
Abdominal CT scan showing pancreatic enlargement and peripancreatic fat stranding. Gallstones are not visible.
Pancreas divisum associated with minor papilla stenosis causing recurrent pancreatitis. Because pancreas divisum is relatively common in general population, it is best regarded as variant of normal anatomy and not necessarily as cause of pancreatitis. In this case, note bulbous contour of duct adjacent to cannula. This appearance has been termed Santorinicele. Dorsal duct outflow obstruction is probable cause of pancreatitis when Santorinicele is present and associated with minor papilla that accommodates only guide wire.
Normal-appearing ventral pancreas in patient with recurrent acute pancreatitis. Dorsal pancreas (not pictured) showed evidence of chronic pancreatitis.
CT scan of abdomen in child with traumatic pancreatitis. Fluid collection adjacent to pancreas will become pseudocyst. Note that pancreas is lacerated, nearly cut in half, by force of abdominal trauma. Also, note typical location of this injury in relation to vertebral column.
CT scan of young man referred 2 weeks into his second bout of severe acute pancreatitis. Gravely ill, he has fever and leukocytosis, as well as hypotension requiring pressors and respiratory distress requiring mechanical ventilation. His abdominal CT scan shows severe acute pancreatitis. Percutaneous drain is placed in dominant fluid collection to establish drainage while he is given imipenem-cilastatin and his condition is stabilized.
Endoscopic retrograde cholangiopancreatography excluded suppurative cholangitis and established presence of anular pancreas divisum. Dorsal pancreatogram showed extravasation into retroperitoneum, and sphincterotomy was performed on minor papilla. Pigtail nasopancreatic tube was then inserted into dorsal duct and out into retroperitoneal fluid collection. Other end of tube was attached to bulb suction and monitored every shift.
While percutaneous drains remove loculated fluid collections elsewhere in the abdomen, nasopancreatic tube is containing retroperitoneal fluid collection. By 1 week later, retroperitoneal fluid collection is much smaller (image is reversed in horizontal direction). By this time, patient is off pressors and is ready to be extubated.
By 4 months later, after pseudocyst has been converted into pseudocystogastrostomy with minimally invasive techniques, pancreatogram reveals more proximal pancreatic duct.
Guide wire is placed into dorsal duct, crosses stenotic area, and advances into proximal duct. Dilating catheter is then advanced over wire to enlarge stenosis. Duct is subsequently stented.
At 6 months after severe acute pancreatitis, patient remains symptom-free and is living independently. As shown in this follow-up abdominal CT scan, minimally invasive techniques were successful in removing pockets of infection, restoring integrity of pancreatic ductal system. They also preserved endocrine function of pancreas, and at this follow-up, patient had no evidence of diabetes mellitus.
Familial adenomatous polyposis syndrome in patient with persistent pancreatitis due to partially obstructing ampullary adenoma. Pancreatogram reveals very prominent ductal system. Because patient had undergone several previous abdominal operations, she opted to have endoscopic ampullectomy.
Stents were placed into biliary and pancreatic ductal systems after ampullectomy. Smoldering pancreatitis resolved within 1 week, stents were subsequently removed, and patient participated in endoscopic surveillance program, with no recurrence to date.
Recurrent pancreatitis associated with pancreas divisum in elderly man. Pancreatogram of dorsal duct shows distal stenosis with upstream chronic pancreatitis. After stenosis was dilated and stented, pain resolved and patient improved clinically during 1 year of quarterly stent exchanges. Follow-up CT scans showed resolution of inflammatory mass. Although ductal biopsies and cytology were repeatedly negative, pain and pancreatitis returned when stents were removed. Patient developed duodenal outflow obstruction and was sent to surgery; Whipple procedure revealed periampullary adenocarcinoma (of minor papilla).
Patient initially seen for recurrent abdominal pain. Esophagogastroduodenoscopy showed submucosal nodule in antrum, which prompted referral to another center, with request for endoscopic ultrasonography (EUS) and polypectomy. EUS was indeterminate, and polypectomy was attempted. That evening, patient developed progressively severe epigastric abdominal pain radiating to back and presented to emergency department. She had leukocytosis and mild lipase elevation and was admitted with diagnosis of pancreatitis. Abdominal CT scan shows circumferential hypodense thickening of antrum, with normal-appearing pancreas. Small portion of pancreatic tissue was later identified as pancreatic rectitis in pathology specimen.
 
 
 
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