General principles of conservative therapy оf acute pancreatitis
Objective: to provide general principles of conservative treatment of acute pancreatitis.
Material and methods. From 1983 to 2013 in the clinic of surgery and endoscopy donetsk national medical university of maxim gorky based on city clinical hospital №16 (donetsk) on treatment were 7368 patients with acute pancreatitis. The age of patients ranged from 18 to 89 years, including patients aged 50 years who comprised 86,5%. The men was 5047 (68.5%), women — 2321 (31.5%), ratio of 2:1. Duration of the disease up to 24 hours was noted in 3116 (42,3%) patients. The period of the disease up to 25 to 72 hours was observed in 1503 (20,4%) patients. Duration of the disease more than 72 hours was marked in 2749 (37,3%) patients. In 3433 (46.6%) patients the cause of acute necrotizing pancreatitis were monotonous food (excessive fatty meal), in 3264 (44.3%) — alcohol consumption (alcohol excess) or its surrogates, the pathology of the terminal part of the common bile duct (the so-called «biliary pancreatitis») — in 383 (5.2%), other causes — in 287 (3.9%). 947 (12.9%) patients were operated. Were treated conservatively — 6421 (87.1%).
Results and discussion. For today is indisputable that the treatment of all patients with acute pancreatitis should be carried out only in a surgical hospital. However, in the general surgical department can be treated only patients with mild (edematous) pancreatitis. The patients with severe (necrotizing) pancreatitis immediately should be hospitalized in the intensive care unit. Conservative treatment of non-severe acute pancreatitis usually is not difficulties. This category includes patients with edematous (interstitial) pancreatitis, as well as with necrotizing pancreatitis with a lesion of pancreatic parenchyma not more than 10 %, as a rule, without parapancreatitis. In an absolute majority of observations treatment of these patients do not require the use of expensive drugs. Аcute pancreatitis in these patients is regressing in 5-7 days. The main directions of the conservative treatment of non-severe acute pancreatitis: painkillers, antispasmodics, drugs that inhibit gastric secretion, infusion therapy, drugs that inhibit the secretion of the pancreas, nutritional support.
The main objectives of intensive therapy in severe acute pancreatitis: maintaining the patient's life, prevention of systemic complications of the disease, the restriction zone parapancreatitis and infection of pancreatic parenchyma. The main systemic complications of acute pancreatitis are acute cardiovascular, respiratory and renal failure. To our deep regret due to late treatment in most patients for medical care, we are not able to influence the restriction zones of necrosis in the pancreas (usually it happens in the next few hours from the disease beginning!).
The main directions of complex conservative treatment of severe acute pancreatitis: adequate analgesia, hemodynamic support, antimicrobial therapy, nutritional support, prevention formation of acute gastroduodenal ulcers and erosions, the suppression of the secretory function of the pancreas, cupping endogenous intoxication, respiratory support, the immune replacement therapy, correction of coagulation and prevention of deep vein thrombosis.
In our opinion, the differences in the intensive care for aseptic and infected necrotizing pancreatitis virtually none. Only exception is the "suppression of the secretory function of the pancreas". These drugs are appropriate to apply only the first few hours of the onset of the disease, but this possibility is quite rare. However, in process of treatment may come to the forefront these or other complications that require correction or amplification of intensive therapy.
Conclusion. Medical therapy is a critical component of complex treatment of patients with acute pancreatitis. A complete conservative therapy in combination
With adequate surgical operation — is the key to the success of the treatment of acute pancreatitis. Today no doubt the thesis that an active conservative therapy should be initiated as early as possible, ie immediately after hospitalization. The basic principle of the complex conservative therapy is its completeness, individual substantiation and impact on all the mechanisms of the pathogenesis of acute pancreatitis with the obligatory based on your stage of the inflammatory process, complications from the abdominal and pleural cavities, as well as systemic complications.
These main directions of conservative treatment of acute pancreatitis are not exhaustive. This is just an attempt to share with colleagues our modest experience in treating this formidable disease as acute pancreatitis. Currently, surgeons and anesthesiologists have a number of highly effective medicines and various supportive measures to ensure a high therapeutic effect of conservative therapy. However, to complete victory, unfortunately, still very, very far away.
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Кондратенко П.Г. Тактика лечения парапанкреатического инфильтрата у больных с остром асептическим некротическим панкреатитом / Кондратенко П.Г., Джансыз И.Н. // Український журнал хірургії. – 2014. – №1 (24). – С. 9-15.
Малков И.С. Лечение острого панкреатита: поиски и решения / Малков И.С. // Практическая медицина. – 2010. – № 2 (10). – С. 24-29.
Плоткин Д.В. Современные принципы медикаментозного лечения острого панкреатита / Плоткин Д.В., Поварихина О.А., Беленцева О.В. // ФАРМиндекс-Практик. – 2005. – Вып. 7. – С. 64-67.
Ярешко В.Г. Клінічні і тактичні особливості діагностики та лікування гострого панкреатиту: методичні рекомендації / Ярешко В.Г., Рязанов Д.Ю. – Запоріжжя, 2004. – 20 с.
Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus / Banks P.A., Bollen T.L., Dervenis C. [et al.] // Gut/ – 2013. – № 62. – Р. 102-111.
Banks P.A. Practice guidelines in acute pancreatitis / Banks P.A., Freeman M.L. // Am. J. Gastroenterol. – 2006. – № 101. – Р. 2379-2400.
Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial / Bakker O.J., van Santvoort H.C., van Brunschot S. [et al.] // JAMA – 2012. – № 307. – Р. 1053-1061.
Brun A. Fluid collections in and around the pancreas in acute pancreatitis / Brun A., Agarwal N., Pitchumoni C.S. // J. Clin. Gastroenterol. – 2011. – № 45. – Р. 614-625.
Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation / Dellinger E.P., Forsmark C.E., Layer P. [et al.] // Ann. Surg. – 2012. – № 256 (6). – P. 875-880.
Fisher J.M. The “golden hours” of management in acute pancreatitis / Fisher J.M., Gardner T.B. // Am. J. Gastroenterol. – 2012. – № 107. – P. 1146-1150.
Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference / Freeman M.L., Werner J., Van Santvoort H.C. [et al.] // Pancreas. – 2012. – № 41. – P. 1176-1194.
Characteristics and outcomes of patients undergoing debridement of pancreatic necrosis / Harrison S., Kakade M., Varadarajula S. [et al.] // J. Gastrointest. Surg. – 2010. – № 14. – P. 245-251.
Aggressive versus conservative initiation of antimicrobial treatment in critically ill surgical patients with suspected intensive-care-unit-acquired infection: a quasi-experimental, before and after observational cohort study / Hranjec T., Rosenberger L., Swenson B. [et al.] // Lancet Infect. Dis. – 2012. – № 12 (10). – P. 774-780.
High quantity and variable quality of guidelines for acute pancreatitis: a systematic review / Loveday B.P., Srinivasa S., Vather R. [et al.] // Am. J. Gastroenterol. – 2010. – № 105. – P. 1466-1476.
Michael J. Hudson Effective Antibiotic Treatment Prescribed by Emergency Physicians in Patients Admitted to the Intensive Care Unit With Severe Sepsis or Septic Shock / Michael J. Hudson, Gregory P. Moore // J. Emerg. Med. – 2011. – № 41 (6). – P. 573-580.
Detailed fluid resuscitation profiles in patients with severe acute pancreatitis / Mole D.J., Hall A., McKeown D. [et al.] // HPB. – 2011. – № 13. – P. 51-58.
Incidence of individual organ dysfunction in fatal acute pancreatitis: analysis of 1024 death records / Mole D.J., Olabi B., Robinson V. [et al.] // HPB. – 2009. – № 11. – P. 166-170.
Mouli V.P. Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and metaanalysis / Mouli V.P., Sreenivas V., Garg P.K. // Gastroenterology. – 2012. – Vol. 144, Issue 2. –P. 333-340.
Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis / Van Baal M.C., Van Santvoort H.C., Bollen T.L. [et al.] // Br. J. Surg. – 2011. – № 98. – P. 18-27.
Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis / Van Santvoort H., Besselink M., Bakker O. [et al.] // N. Engl. J. Med. – 2010. – № 362. – P. 1491-1502.
Burden of gastrointestinal disease in the United States: 2012 update / Peery A.F., Dellon E.S., Lund J. [et al.] // Gastroenterology. – 2012. – Vol. 143, Issue 5. – P. 1179-1187.
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