eMedicine Specialties > Emergency Medicine > Gastrointestinal

Pancreatitis: Treatment & Medication

Author: Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Coauthor(s): Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Contributor Information and Disclosures

Updated: Jan 26, 2009

Treatment

Emergency Department Care

Most of the cases presenting to the ED are treated conservatively, and approximately 80% respond to such treatment.3

  • Fluid resuscitation
    • Monitor accurate intake/output and electrolyte balance of the patient.
    • Crystalloids are used, but other infusions, such as packed red blood cells (PRBCs), are occasionally administered, particularly in the case of hemorrhagic pancreatitis.
    • Central lines and Swan-Ganz catheters are used in patients with severe fluid loss and very low blood pressure.
  • If the patient is not vomiting well, an NG is not necessary, but if the patient is vomiting continuously, then an NG tube is warranted for symptomatic relief and to avoid aspiration.
  • Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of the latter on the sphincter of Oddi.
  • Antibiotics are used in severe cases associated with septic shock or when the CT scan indicates that a phlegmon of the pancreas has evolved.
  • Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third-generation cephalosporins.
  • Continuous oxygen saturation should be monitored by pulse oximetry, and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed.
  • Perform CT-guided aspiration of necrotic areas, if necessary.
  • An ERCP may be indicated for common duct stone removal.

Consultations

Consult a general surgeon in the following cases:

  • For phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue. It should be followed by postoperative lavage of the pancreatic bed.
  • In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis.
  • Patients who fail to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room. Surgery in these cases may lead to a better outcome or confirm a different diagnosis.
  • In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction. A cholecystectomy may be performed to clear the system from any source of biliary stones.

Medication

The goal of pharmacotherapy is to relieve pain and minimize complications.

Antibiotics

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


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Adult

1-2 g IM/IV once or divided bid

Pediatric

50-75 mg/kg/d IM/IV divided q12h

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin


Ampicillin (Marcillin, Omnipen)

Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.

Adult

250-500 mg IM/IV q6h

Pediatric

25-50 mg/kg/d IM/IV divided q6-8h

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Documented hypersensitivity; viral mononucleosis

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Analgesics

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.


Meperidine (Demerol)

Analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Adult

15-35 mg/h IV; 50-150 mg IM q3-4h

Pediatric

1.1-1.8 mg/kg IM q3-4h

Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects; avoid with protease inhibitors

Documented hypersensitivity; MAOIs; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in head injuries because may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex); substantially increased dose levels may aggravate or cause seizures because of tolerance, even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity if seizure history exists

More on Pancreatitis

Overview: Pancreatitis
Differential Diagnoses & Workup: Pancreatitis
Treatment & Medication: Pancreatitis
Follow-up: Pancreatitis
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Ghattas Khoury, MD, Clinical Professor, President, Lebanese Order of Physicians, Department of Surgery, American University of Beirut
Ghattas Khoury, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Samer S Deeba, MD, Fellow, Department of Surgery, St Mary's Hospital, Imperial College, London
Disclosure: Nothing to disclose.

Medical Editor

Jerome FX Naradzay, MD, FACEP, Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina
Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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