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).
Analgesics, Other
Class Summary
Pain control is essential for 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 Propoxyphene products were withdrawn from the US market on November 19, 2010.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.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Acetaminophen is a peripherally acting drug of choice for mild to moderate pain and elevation of body temperature.
Tramadol (Ultram, Ryzolt, Rybix)
Tramadol is a centrally acting analgesic for moderately severe pain. It inhibits the ascending pain pathways, altering perception of and response to pain. It also inhibits reuptake of norepinephrine and serotonin.
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.
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.
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 the 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.
Ampicillin
Ampicillin has bactericidal activity against susceptible organisms. It is an alternative to amoxicillin when the patient is unable to take medication orally.
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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Acute pancreatitis. Suspected acute pancreatitis. Etiologic factors and forms of acute pancreatitis. Ranson criteria.
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Acute pancreatitis. Mild pancreatitis. Favorable prognostic signs for acute pancreatitis. Medical management and studies used for acute pancreatitis.
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Acute pancreatitis. Prognostic indicators for severe pancreatitis and intensive care unit management.
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Acute pancreatitis. Diagnosis and treatment of necrotizing pancreatitis.
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Acute pancreatitis. Treatment of and studies used for pancreatic pseudocysts.
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Acute pancreatitis. Idiopathic recurrent pancreatitis. Etiologies for acute pancreatitis.
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Acute pancreatitis. Pancreatic abscess. Definition of an abscess.
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Acute pancreatitis. A patient with acute gallstone pancreatitis underwent endoscopic retrograde cholangiopancreatography. The cholangiogram showed no stones in the common bile duct and multiple small stones in the gallbladder. The pancreatogram shows narrowing of the pancreatic duct in the area of genu, resulting from extrinsic compression of the ductal system by inflammatory changes in the pancreas.
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Acute pancreatitis. This image was obtained from a patient with pancreas divisum associated with minor papilla stenosis causing recurrent pancreatitis. Because pancreas divisum is relatively common in the general population, it is best regarded as a variant of normal anatomy and not necessarily as a cause of pancreatitis. In this case, note the bulbous contour of the duct adjacent to the cannula. This appearance has been termed Santorinicele. Dorsal duct outflow obstruction is a probable cause of pancreatitis when Santorinicele is present, and it is associated with a minor papilla that accommodates only a guide wire.
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Acute pancreatitis. A normal-appearing ventral pancreas is seen in a patient with recurrent acute pancreatitis. Dorsal pancreas (not pictured) showed evidence of chronic pancreatitis.
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Acute pancreatitis. Endoscopic retrograde cholangiopancreatography excluded suppurative cholangitis and established the presence of anular pancreas divisum. The dorsal pancreatogram showed extravasation into the retroperitoneum, and sphincterotomy was performed on the minor papilla. A pigtail nasopancreatic tube was then inserted into the dorsal duct and out into the retroperitoneal fluid collection. The other end of the tube was attached to bulb suction and monitored every shift.
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Acute pancreatitis. Although percutaneous drains remove loculated fluid collections elsewhere in the abdomen, a nasopancreatic tube drains the retroperitoneal fluid collection. One week later, the retroperitoneal fluid collection was much smaller (the image is reversed in a horizontal direction). By this time, the patient was off pressors and was ready to be extubated.
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Acute pancreatitis. Recurrent pancreatitis was associated with pancreas divisum in an elderly man. The pancreatogram of the dorsal duct shows distal stenosis with upstream chronic pancreatitis. After the stenosis was dilated and stented, his pain resolved and the patient improved clinically during 1 year of quarterly stent exchanges. Follow-up computed tomography (CT) scans showed resolution of the inflammatory mass. Although ductal biopsies and cytology were repeatedly negative, the patient's pain and pancreatitis returned when the stents were removed. He developed duodenal outflow obstruction and was sent to surgery; during the Whipple procedure, periampullary adenocarcinoma (of minor papilla) was revealed.
Tables
| Acute pancreatitis (any) or a history of post-ERCP pancreatitis |
| Younger age |
| Female sex |
| Absence of bile duct stones |
| More than 10 attempts to cannulate the papilla of Vater |
| Pancreatic duct cannulation |
| Contrast medium injection of the pancreatic system |
| Pancreatic sphincterotomy |
| Sphincter of Oddi dysfunction |
