Acute pancreatitis refers to the activation of pancreatic enzymes caused by various etiologies, followed by a local inflammatory response of the pancreas as the main feature, and in severe cases, a systemic inflammatory response syndrome may occur, and may be accompanied by organ dysfunction.
A. Treatment for the cause
1.Acute pancreatitis of biliary origin.
Gallstone disease is currently the main causative factor of acute pancreatitis in China. Anyone with biliary stone obstruction needs to be released from the obstruction in time, and the treatment includes endoscopic or surgical treatment. MAP patients with gallbladder stones should undergo cholecystectomy as soon as possible after disease control, while patients with necrotizing pancreatitis can be treated together with necrotic tissue removal at a later stage or elective treatment after disease control.
2, hyperlipidemic acute pancreatitis.
AP combined with venous celiac blood or blood triglycerides >11, 3 mmol/L can be clearly diagnosed, and triglyceride levels need to be lowered for a short time, as much as possible to below 5, 65 mmol/L. Such patients should limit the use of fat emulsions and avoid the application of drugs that may elevate lipids. Treatment can be low-dose low molecular heparin and insulin, or lipid adsorption and plasma replacement for rapid lipid lowering.
3. Other etiologies.
Hypercalcemic pancreatitis is mostly associated with hyperparathyroidism, which requires calcium-lowering therapy. The anatomical and physiological abnormalities of the pancreas, drugs, pancreatic tumors and other causes should be treated accordingly.
Non-surgical treatment
1.General treatment.
It includes fasting, gastrointestinal decompression, pharmacological treatment including antispasmodic, analgesic, protease inhibitors and pancreatic enzyme inhibition therapy, such as growth inhibitors and their analogues.
2, fluid resuscitation and intensive care treatment.
Fluid resuscitation, maintenance of water-electrolyte balance and intensive monitoring therapy are the focus of early treatment. As SIRS causes capillary leaksyndrome (CLS), which leads to massive leakage of blood components, resulting in blood volume loss and hematoconcentration. Resuscitation fluid is preferred to lactated Ringer’s solution, and plasma substitute can be used in appropriate amounts for patients requiring rapid resuscitation. Volume expansion therapy needs to avoid insufficient or excessive fluid resuscitation, which can be guided by dynamic monitoring of central venous pressure (CVP) or pulmonary capillary wedge pressure (PWCP), heart rate, blood pressure, urine volume, erythrocyte specific volume (HCT) and mixed venous oxygen saturation (SvO2).
3. Treatment for maintenance of organ function.
(1) For the treatment of respiratory failure: give nasal catheter or face mask oxygen, maintain oxygen saturation above 95%, dynamically monitor blood gas analysis results, and apply mechanical ventilation if necessary.
(2) Treatment for acute renal failure: early prevention of acute renal failure is mainly volume resuscitation and other supportive therapy to stabilize hemodynamics; treatment of acute renal failure is mainly continuous renalreplacement therapy (CRRT).
(3) Support for other organ functions: liver function abnormalities can be treated with hepatoprotective drugs, acute gastric mucosal injury requires the application of proton pump inhibitors or H2 receptor antagonists.
4.Nutritional support.
Before intestinal function is restored, parenteral nutrition can be used as appropriate; once intestinal function is restored, enteral nutrition should be performed as soon as possible. Adopt nasojejunal tube or nasogastric tube infusion method, pay attention to the formula, temperature, concentration and infusion speed of nutrition preparation, and adjust according to the tolerance situation.
5.Antibiotic application.
Intravenous use of antibiotics to prevent infection is not recommended for patients with AP. For possible intestinal-derived bacterial translocation in some susceptible groups (such as biliary obstruction, advanced age, immunocompromised, etc.), quinolones, cephalosporins, carbapenems and metronidazole can be selected for infection prevention.
6.Chinese medicine treatment.
Chinese herbal medicine treatment can be used to promote the recovery of gastrointestinal function and the absorption of pancreatic inflammation, including internal administration, external application or enema of Chinese herbs that regulate qi and attack the lower part of the body.
Treatment of ACS
Patients with MSAP or SAP can be combined with ACS, and when intra-abdominal pressure (IAP) is >20 mmHg (1 mmHg=0.133 kPa), it is often accompanied by new organ failure, thus becoming an important cause of death in MSAP or SAP. A simple and practical method to determine IAP is transcatheter cystometry, in which the patient is lying down with the pubic symphysis as the 0 point, and after emptying the bladder, 50 ml of saline is injected into the bladder through the catheter, and the height of the water column at equilibrium is measured as IAP. Ultrasound or CT-guided intraperitoneal and retroperitoneal drainage to reduce abdominal pressure. ACS is not recommended as an indication for open surgery in the early stages of AP.
IV. Surgical treatment
Surgical treatment is mainly aimed at local complications of the pancreas secondary to infection or producing compression symptoms, such as gastrointestinal obstruction and biliary obstruction, as well as other complications such as pancreatic fistula, gastrointestinal fistula and ruptured bleeding pseudoaneurysm. Asymptomatic aseptic necrotic effusion of the pancreas and peripancreatic does not require surgical treatment.
1. Indications and timing of surgery for infected necrosis of the pancreas and peripancreatic.
Those with clinical sepsis, bubble sign on CT examination, fine needle aspiration aspirate smear or culture to find bacteria or fungi can be diagnosed as infected necrosis and need to consider surgical treatment. Ultrasound or CT-guided percutaneouscatheterdrainage (PCD) of pancreatic or peripancreatic infected pus to relieve toxic symptoms can be used as a transitional treatment before surgery. . The results of some studies have shown that early surgical treatment significantly increases the number of operations, the incidence of postoperative complications and the morbidity and mortality rate.
2. Surgical modalities for infected necrosis of the pancreas and peripancreatic.
The surgical modalities for pancreatic infective necrosis can be divided into PCD, endoscopic, minimally invasive surgery and open surgery. Minimally invasive surgery mainly includes small incision surgery, video-assisted surgery (laparoscopy, nephroscopy, etc.). Open surgery includes transabdominal or retroperitoneal route of pancreatic necrotic tissue removal and duct placement for drainage. For patients with biliary stones, additional cholecystectomy or choledochotomy for stone extraction may be considered, and intraoperative placement of a jejunal nutrient tube is recommended. Infected necrosis of the pancreas is a complex and diverse condition, and various surgical procedures must follow individualized principles applied individually or in combination.
3. Principles of treatment of local complications.
(1) APFC and ANC: asymptomatic people do not need surgical treatment; those with obvious symptoms, gastrointestinal compression symptoms, affecting enteral nutrition or feeding, or secondary infection, can be treated with PCD under ultrasound or CT guidance, and further surgical treatment is needed if infection or compression symptoms are not relieved.
(2) WON: aseptic WON, in principle, is not treated surgically and is observed on follow-up visits; when infection occurs, PCD or surgical treatment is feasible.
(3) pancreatic pseudocyst: secondary to infection, treatment is the same as WON, no symptoms, no treatment, follow-up observation; if the volume increases and compression symptoms appear, surgical treatment is required. Surgical treatment is based on internal drainage surgery, and internal drainage surgery can be performed under laparoscopy or open surgery.
4. Treatment of other complications.
Pancreatic fistula is mostly caused by inflammation, necrosis and infection of the pancreas leading to rupture of the pancreatic duct. The treatment of pancreatic fistula includes patulous drainage and suppression of pancreatic secretion and endoscopic and surgical treatment.