New Approaches for the Treatment of Acute Pancreatitis

Posted by e-Medical PPT Monday, October 1, 2012
In the last few years, several new therapeutic options have changed the management of acute pancreatitis; for example, the therapeutic ERCP with endoscopic sphincterotomy in severe biliary pancreatitis, the use of early antibiotic treatment in necrotizing pancreatitis and the demonstration that enteral feeding is able to decrease the inflammatory response. In this paper we describe the therapeutic news which could modify the current approach to acute pancreatitis in the near future. This is possible only because we have new information in order to better understand the pathophysiological processes of the disease.

In recent years, a number of articles have been published on the treatment of acute pancreatitis in experimental models and most of them were published about animals with mild disease. However, it is difficult to translate these results into clinical practice. For example, infliximab, a monoclonal TNF antibody, was experimentally tested in rats and it was able to significantly reduce the pathologic score and serum amylase activity, and also alleviate alveolar edema and acute respiratory distress syndrome; no studies are available in clinical human acute pancreatitis. Another substance, such as interleukin 10, was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, but seems to have no effect on human severe acute pancreatitis. Thus, the main problem in acute pancreatitis, especially in the severe form of the disease, is the difficulty of planning clinical studies capable of giving hard statistically significant answers regarding the benefits of the various proposed therapeutic agents previously tested in experimental settings.
According to the pathophysiology of acute pancreatitis, we may re-evaluate the efficacy of the drugs already available, such as gabexate mesilate, lexipafant and somatostatin which should be probably administered in a different manner. Of course, also in this case, we need large studies to test this hypothesis.
Another great problem is prevention of the infection of pancreatic necrosis. A randomized study has been published to test the hypothesis that probiotics and specific fibres used as supplements in early enteral nutrition may be effective in reducing pancreatic sepsis and the number of surgical interventions. A study named PROPATRIA (Probiotic Prophylaxis in Patients with Predicted Severe Acute Pancreatitis) has been planned to give a more robust confirmation to the previous study. Furthermore, the open question of the prevention of the fungal infection of necrosis is still being debated.
Finally, the prevention of pain relapse after oral feeding in patients with mild or severe acute pancreatitis should be explored. Even if some studies exist on this issue, the question of optimal treatment is still unanswered.
As in other diseases, obtaining results when treating patients with acute pancreatitis is difficult and will take continuous small steps.

Severity Classification of Acute Pancreatitis:from the Pathological to the Clinical Point of View
Marseille (pathological classification)
Edematous acute pancreatitis
Necrotizing acute pancreatitis

Atlanta (clinical classification)
Mild acute pancreatitis
Severe acute pancreatitis

Basic Management of Acute Pancreatitis
The Control of Pain
The Control of Nausea, Vomiting, Ileus
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