Monitoring and therapy of acute pancreatitis

Acute pancreatitis is a potentially life-threatening disorder with a rapid course of development; therefore, the time frame for diagnosis and treatment is narrow. Early diagnosis and therapy of severe necrotizing pancreatitis is of paramount importance with a mortality of 15-42%. In contrast mild edematous pancreatitis has a fatal course in only 1% of cases. Prediction of severity is impeded by a marked time dependency of the prognostic value of the different predictors; therefore, an exact determination of the onset of pain is highly relevant. At least three prognostic scenarios with different values for prognostic markers have to be taken into account. In the emergency room scenario, several simple parameters have a high prognostic value: increased blood glucose, increased hematocrit and increased blood urea nitrogen (BUN) have been demonstrated to be predictors with high sensitivity and high negative predictive value but low specificity and low positive predictive value. Furthermore, the relatively straightforward bedside index of severity in acute pancreatitis (BISAP) score has been validated to accurately predict prognosis. In the early re-evaluation scenario after 48 h the acute physiology and chronic health examination (APACHE) II score (cutoff 8 points) and the Ranson score (cut-off 3 points) provide high prognostic accuracy. For patients admitted to the intensive care unit (ICU admission scenario) specific markers of organ failure are available. The results of meta-analyses confirm a therapeutic effectiveness with limited effect size for the use of endoscopic retrograde cholangiography in severe biliary pancreatitis particularly in cases of cholangitis, for antibiotics (imipenem) in necrotizing pancreatitis and for early enteral feeding. An association of poor prognosis with increases in BUN and the hematocrit suggests the use of early goal-directed volume replacement which should be tailored to the clinical picture, echocardiography and/or modern hemodynamic parameters instead of central venous pressure which is unsuitable. Severe pain usually requires the use of opioid analgesia. Even when necrosis is present, conservative management (radiologically or endoscopically placed drainage) is appropriate. If these therapeutic approaches are not successful or cannot be managed technically, a surgical step-up should be considered.