Treatment of Severe Acute Pancreatitis

  • Peter Draganov
Part of the Clinical Gastroenterology book series (CG)


Acute pancreatitis (AP) is a protean disease capable of wide clinical variation, ranging from mild discomfort to overwhelming organ failure and death. This chapter introduces definitions, discusses the diagnosis of severe AP (SAP), and examines in detail the various therapeutic options for management of patients with SAP.


Acute Pancreatitis Acute Pancreatitis Severe Acute Pancreatitis Bile Duct Stone Pancreatic Necrosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993; 128: 586–590.PubMedGoogle Scholar
  2. 2.
    Siegelman SS, Copeland BE, Saba GP, et al. CT of fluid collections associated with pancreatitis. Am J Roentgenol 1980; 134: 1121–1132.Google Scholar
  3. 3.
    Bittner R, Block S, Buchler M, et al. Pancreatic abscess and infected pancreatic necrosis. Different local septic complications in acute pancreatitis. Dig Dis Sci 1987; 32: 1082–1087.PubMedCrossRefGoogle Scholar
  4. 4.
    VanSonnenberg E, Wittich GR, Casola G, et al. Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases. Radiology 1989; 170: 757–761.PubMedGoogle Scholar
  5. 5.
    Bradley EL, Gonzalez AC, Clements JL Jr. Acute pancreatic pseudocysts: incidence and implications. Ann Surg 1976; 184: 734–737.PubMedCrossRefGoogle Scholar
  6. 6.
    Johnson DH, Arteaga CL. Gefitinib in recurrent non-small-cell lung cancer: an IDEAL trial? J Clin Oncol 2003; 21: 2227–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Ranson JH, Rifkind KM, Turner JW. Prognostic signs and nonoperative peritoneal lavage in acute pancreatitis. Surg Gynecol Obstet 1976; 143: 209–219.PubMedGoogle Scholar
  8. 8.
    Beger HG, Bittner R, Buchler M, et al. Hemodynamic data pattern in patients with acute pancreatitis. Gastroenterology 1986; 90: 74–79.PubMedGoogle Scholar
  9. 9.
    Kyogoku T, Manabe T, Tobe T. Role of ischemia in acute pancreatitis. Hemorrhagic shock converts edematous pancreatitis to hemorrhagic pancreatitis in rats. Dig Dis Sci 1992; 37: 1409–1417.PubMedCrossRefGoogle Scholar
  10. 10.
    Interiano B, Stuard ID, Hyde RW. Acute respiratory distress syndrome in pancreatitis. Ann Intern Med 1972; 77: 923–926.PubMedGoogle Scholar
  11. 11.
    Ranson JH, Turner JW, Roses DF, et al. Respiratory complications in acute pancreatitis. Ann Surg 1974; 179: 557–566.PubMedGoogle Scholar
  12. 12.
    Werner MH, Hayes DF, Lucas CE, et al. Renal vasoconstriction in association with acute pancreatitis. Am J Surg 1974; 127: 185–190.PubMedCrossRefGoogle Scholar
  13. 13.
    Goldstein DA, Llach F, Massry SG. Acute renal failure in patients with acute pancreatitis. Arch Intern Med 1976; 136: 1363–1365.PubMedCrossRefGoogle Scholar
  14. 14.
    Allam BF, Imrie CW. Serum ionized calcium in acute pancreatitis. Br J Surg 1977; 64: 665–668.PubMedCrossRefGoogle Scholar
  15. 15.
    Imrie CW, Whyte AS. A prospective study of acute pancreatitis. Br J Surg 1975; 62: 490–494.PubMedCrossRefGoogle Scholar
  16. 16.
    Cameron JL, Capuzzi DM, Zuidema GD, et al. Acute pancreatitis with hyperlipemia: the incidence of lipid abnormalities in acute pancreatitis. Ann Surg 1973; 177: 483–489.PubMedCrossRefGoogle Scholar
  17. 17.
    Vogel RM, Keohane M. Renal vascular abnormalities in acute pancreatitis. Arch Intern Med 1967; 119: 610–616.PubMedCrossRefGoogle Scholar
  18. 18.
    Greipp PR, Brown JA, Gralnick HR. Defibrination in acute pancreatitis. Ann Intern Med 1972; 76: 73–76.PubMedGoogle Scholar
  19. 19.
    Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139: 69–81.PubMedGoogle Scholar
  20. 20.
    Dominguez-Munoz JE, Malfertheiner P, Ditschuneit HH, et al. Hyperlipidemia in acute pancreatitis. Relationship with etiology, onset, and severity of the disease. Int J Pancreatol 1991; 10:261–267.PubMedGoogle Scholar
  21. 21.
    Salomone T, Tosi P, Palareti G, et al. Coagulative disorders in human acute pancreatitis: role for the D-dimer. Pancreas 2003; 26: 111–116.PubMedCrossRefGoogle Scholar
  22. 22.
    Jacobs ML, Daggett WM, Civette JM, et al. Acute pancreatitis: analysis of factors influencing survival. Ann Surg 1977; 185: 43–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Marks IN, Bank S, Louw JH, et al. Peptic ulceration and gastrointestinal bleeding in pancreatitis. Gut 1967; 8: 253–259.PubMedCrossRefGoogle Scholar
  24. 24.
    Little AG, Moossa AR. Gastrointestinal hemorrhage from left-sided portal hypertension. An unappreciated complication of pancreatitis. Am J Surg 1981; 141: 153–158.PubMedCrossRefGoogle Scholar
  25. 25.
    Madsen MS, Petersen TH, Sommer H. Segmental portal hypertension. Ann Surg 1986; 204: 72–77.PubMedCrossRefGoogle Scholar
  26. 26.
    Stroud WH, Cullom JW, Anderson MC. Hemorrhagic complications of severe pancreatitis. Surgery 1981; 90: 657–665.PubMedGoogle Scholar
  27. 27.
    Lankisch PG, Struckmann K, Assmus C, et al. Do we need a computed tomography examination in all patients with acute pancreatitis within 72 h after admission to hospital for the detection of pancreatic necrosis? Scand J Gastroenterol 2001; 36: 432–436.PubMedCrossRefGoogle Scholar
  28. 28.
    Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174: 331–336.PubMedGoogle Scholar
  29. 29.
    Balthazar EJ, Freeny PC, vanSonnenberg E., et al. Imaging and intervention in acute pancreatitis. Radiology 1994; 193: 297–306.PubMedGoogle Scholar
  30. 30.
    Freeny PC. Incremental dynamic bolus computed tomography of acute pancreatitis. Int J Pancreatol 1993; 13:147–158.PubMedGoogle Scholar
  31. 31.
    Balthazar EJ, Robinson DL, Megibow AJ, et al. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174: 331–336.PubMedGoogle Scholar
  32. 32.
    Lankisch PG, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis. Pancreas 2000; 20: 319–322.PubMedCrossRefGoogle Scholar
  33. 33.
    Schmidt J, Hotz HG, Foitzik T, et al. Intravenous contrast medium aggravates the impairment of pancreatic microcirculation in necrotizing pancreatitis in the rat. Ann Surg 1995; 221: 257–264.PubMedCrossRefGoogle Scholar
  34. 34.
    Foitzik T, Lewandrowski KB, Fernandez-del Castillo C, et al. Exocrine hyper-stimulation but not pancreatic duct obstruction increases the susceptibility to alcohol-related pancreatic injury. Arch Surg 1994; 129: 1081–1085.PubMedGoogle Scholar
  35. 35.
    McMenamin DA, Gates LK Jr. A retrospective analysis of the effect of contrastenhanced CT on the outcome of acute pancreatitis. Am J Gastroenterol 1996; 91: 1384–1387.PubMedGoogle Scholar
  36. 36.
    Carmona-Sanchez R, Uscanga L, Bezaury-Rivas P, et al. Potential harmful effect of iodinated intravenous contrast medium on the clinical course of mild acute pancreatitis. Arch Surg 2000; 135: 1280–1284.PubMedCrossRefGoogle Scholar
  37. 37.
    De Bernardinis M, Violi V, Roncoroni L, et al. Discriminant power and information content of Ranson’s prognostic signs in acute pancreatitis: a meta-analytic study. Crit Care Med 1999; 27: 2272–2283.PubMedCrossRefGoogle Scholar
  38. 38.
    Bradley EL 3rd, Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. Am J Surg 1991; 161: 19–24.PubMedCrossRefGoogle Scholar
  39. 39.
    Banks PA, Gerzof SG, Langevin RE, et al. CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome. Int J Pancreatol. 1995; 18: 265–270.PubMedGoogle Scholar
  40. 40.
    Knight MJ, Condon JR, Day JL. Possible role of glucagon in pathogenesis of acute pancreatitis. Lancet 1972; 1: 1097–1099.PubMedCrossRefGoogle Scholar
  41. 41.
    Anonymous. Death from acute pancreatitis. M.R.C. multicentre trial of glucagon and aprotinin. Lancet 1977; 2: 632–635.Google Scholar
  42. 42.
    Waterworth MW, Barbezat GO, Bank S. Glucagon in treatment of acute pancreatitis. Lancet 1974; 1: 1231.PubMedCrossRefGoogle Scholar
  43. 43.
    Durr HK, Maroske D, Zelder O, et al. Glucagon therapy in acute pancreatitis. Report of a double-blind trial. Gut 1978; 19: 175–179.PubMedCrossRefGoogle Scholar
  44. 44.
    Cameron JL, Mehigan D, Zuidema GD. Evaluation of atropine in acute pancreatitis. Surg Gynecol Obstet 1979; 148: 206–208.PubMedGoogle Scholar
  45. 45.
    Broe PJ, Zinner MJ, Cameron JL. A clinical trial of cimetidine in acute pancreatitis. Surg Gynecol Obstet 1982; 154: 13–16.PubMedGoogle Scholar
  46. 46.
    Meshkinpour H, Molinari MD, Gardner L, et al. Cimetidine in the treatment of acute alcoholic pancreatitis. A randomized, double-blind study. Gastroenterology 1979; 77: 687–690.PubMedGoogle Scholar
  47. 47.
    Hadas N, Wapnick S, Grosberg SJ. Cimetidine in pancreatitis. N Engl J Med 1978; 299: 487.PubMedGoogle Scholar
  48. 48.
    Trapnell JE, Rigby CC, Talbot CH, et al. Acontrolled trial of Trasylol in the treatment of acute pancreatitis. Br J Surg 1974; 61: 177–182.PubMedCrossRefGoogle Scholar
  49. 49.
    Trapnell JE, Talbot CH, Capper WM. Trasylol in acute pancreatitis. Am J Dig Dis 1967; 12: 409–412.PubMedCrossRefGoogle Scholar
  50. 50.
    Imrie CW, Benjamin IS, Ferguson JC, et al. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br J Surg 1978; 65: 337–341.PubMedCrossRefGoogle Scholar
  51. 51.
    Buchler M, Malfertheiner P, Uhl W, et al. Gabexate mesilate in human acute pancreatitis. German Pancreatitis Study Group. Gastroenterology 1993; 104: 1165–1170.PubMedGoogle Scholar
  52. 52.
    Goebell H, Ammann R, Herfarth C, et al. A double-blind trial of synthetic salmon calcitonin in the treatment of acute pancreatitis. Scand J Gastroenterol 1979; 14: 881–889.PubMedCrossRefGoogle Scholar
  53. 53.
    Usadel KH, Leuschner U, Uberla KK. Treatment of acute pancreatitis with somatostatin: a multicenter double blind study. N Engl J Med 1980; 303: 999–1000.PubMedCrossRefGoogle Scholar
  54. 54.
    Choi TK, Mok F, Zhan WH, et al. Somatostatin in the treatment of acute pancreatitis: a prospective randomised controlled trial. Gut 1989; 30: 223–227.PubMedCrossRefGoogle Scholar
  55. 55.
    Bordas JM, Toledo V, Mondelo F, et al. Prevention of pancreatic reactions by bolus somatostatin administration in patients undergoing endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy. Horm Res 1988; 29: 106–108.PubMedGoogle Scholar
  56. 56.
    Uhl W, Buchler MW, Malfertheiner P, et al. A randomised, double blind, multicentre trial of octreotide in moderate to severe acute pancreatitis. Gut 1999; 45: 97–104.PubMedCrossRefGoogle Scholar
  57. 57.
    Johnson CD, Kingsnorth AN, Imrie CW, et al. Double blind, randomised, placebo controlled study of a platelet activating factor antagonist, lexipafant, in the treatment and prevention of organ failure in predicted severe acute pancreatitis. Gut 2001; 48: 62–69.PubMedCrossRefGoogle Scholar
  58. 58.
    Larvin M and the international lexipifant study group. A double blind randomised controlled multi-centre trial of lexipifant in acute pancreatitis. Pancreas 2001; 23 (abstract): 448Google Scholar
  59. 59.
    Marshall JB. Acute pancreatitis. A review with an emphasis on new developments. Arch Intern Med 1993; 153: 1185–1198.PubMedCrossRefGoogle Scholar
  60. 60.
    Lankisch PG, Haseloff M, Becher R. No parallel between the biochemical course of acute pancreatitis and morphologic findings. Pancreas 1994; 9: 240–243.PubMedCrossRefGoogle Scholar
  61. 61.
    Seidensticker F, Otto J, Lankisch PG. Recovery of the pancreas after acute pancreatitis is not necessarily complete. Int J Pancreatol 1995; 17: 225–229.PubMedGoogle Scholar
  62. 62.
    Levy P, Heresbach D, Pariente EA, et al. Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients. Gut 1997; 40: 262–266.PubMedGoogle Scholar
  63. 63.
    Naeije R, Salingret E, Clumeck N, et al. Is nasogastric suction necessary in acute pancreatitis? Br Med J 1978; 2: 659–660.PubMedCrossRefGoogle Scholar
  64. 64.
    Loiudice TA, Lang J, Mehta H, et al. Treatment of acute alcoholic pancreatitis: the roles of cimetidine and nasogastric suction. Am J Gastroenterol 1984; 79: 553–558.PubMedGoogle Scholar
  65. 65.
    Reynaert MS, Dugernier T, Kestens PJ. Current therapeutic strategies in severe acute pancreatitis. Intensive Care Med 1990; 16: 352–362.PubMedCrossRefGoogle Scholar
  66. 66.
    Grant JP, James S, Grabowski V, et al. Total parenteral nutrition in pancreatic disease. Ann Surg 1984; 200: 627–631.PubMedCrossRefGoogle Scholar
  67. 67.
    Runkel NS, Rodriguez LF, Moody FG. Mechanisms of sepsis in acute pancreatitis in opossums. Am J Surg 1995; 169: 227–232.PubMedCrossRefGoogle Scholar
  68. 68.
    Medich DS, Lee TK, Melhem MF, et al. Pathogenesis of pancreatic sepsis. Am J Surg 1993; 165: 46–50.PubMedCrossRefGoogle Scholar
  69. 69.
    Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997; 84:1665–1669.PubMedCrossRefGoogle Scholar
  70. 70.
    Al-Omran M, Groof A, Wilke D. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev 2001; 2: CD002837.Google Scholar
  71. 71.
    Abou-Assi S, Craig K, O’Keefe SJ. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002; 97: 2255–2262.PubMedCrossRefGoogle Scholar
  72. 72.
    Neoptolemos JP, Carr-Locke DL, London N, et al. ERCP findings and the role of endoscopic sphincterotomy in acute gallstone pancreatitis. Br J Surg 1988; 75: 954–960.PubMedCrossRefGoogle Scholar
  73. 73.
    Fan ST, Lai EC, Mok FP, et al. Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 1993; 328: 228–232.PubMedCrossRefGoogle Scholar
  74. 74.
    Folsch UR, Nitsche R, Ludtke R, et al. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis. N Engl J Med 1997; 336: 237–242.PubMedCrossRefGoogle Scholar
  75. 75.
    Kramer KM, Levy H. Prophylactic antibiotics for severe acute pancreatitis: the beginning of an era. Pharmacotherapy 1999; 19: 592–602.PubMedCrossRefGoogle Scholar
  76. 76.
    Pederzoli P, Bassi C, Vesentini S, et al. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993; 176: 480–483.PubMedGoogle Scholar
  77. 77.
    Sainio V, Kemppainen E, Puolakkainen P, et al. Early antibiotic treatment in acute necrotising pancreatitis. Lancet 1995; 346: 663–667.PubMedCrossRefGoogle Scholar
  78. 78.
    Delcenserie R, Yzet T, Ducroix JP. Prophylactic antibiotics in treatment of severe acute alcoholic pancreatitis. Pancreas 1996; 13: 198–201.PubMedGoogle Scholar
  79. 79.
    Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas 2001; 22: 28–31.PubMedCrossRefGoogle Scholar
  80. 80.
    Banks PA. Practice guidelines in acute pancreatitis. Am J Gastroenterol 1997; 92: 377–386.PubMedGoogle Scholar
  81. 81.
    Farkas G, Marton J, Mandi Y, et al. Progress in the management and treatment of infected pancreatic necrosis. Scand J Gastroenterol Suppl 1998; 228: 31–37.PubMedCrossRefGoogle Scholar
  82. 82.
    Rau B, Uhl W, Buchler MW, et al. Surgical treatment of infected necrosis. World J Surg 1997; 21: 155–161.PubMedCrossRefGoogle Scholar
  83. 83.
    Baron TH, Morgan DE. Endoscopic transgastric irrigation tube placement via PEG for debridement of organized pancreatic necrosis. Gastrointest Endosc 1999; 50: 574–577.PubMedCrossRefGoogle Scholar
  84. 84.
    Monkemuller KE, Baron TH, Morgan DE. Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique. Gastrointest Endosc 1998; 48: 195–200.PubMedCrossRefGoogle Scholar
  85. 85.
    Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56: 7–17.PubMedCrossRefGoogle Scholar
  86. 86.
    Baron TH, Thaggard WG, Morgan DE, et al. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996; 111: 755–764.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2005

Authors and Affiliations

  • Peter Draganov
    • 1
  1. 1.Division of Gastroenterology, Hepatology, and NutritionUniversity of Florida College of MedicineGainesville

Personalised recommendations