Treatment of severe acute pancreatitis

In Germany, acute pancreatitis (AP) has an incidence of 30-45 cases per 100,000 person-years. More than two of three cases are caused by gallstones or alcohol. Iatrogenic, metabolic or malignant etiologies are markedly less frequent. Diagnosis is established based on the typical epigastric pain radiating to the back and a three-fold increase in serum lipase or amylase. Early prognosis is crucial to optimize therapy in patients with severe AP with a mortality of up to 42%. Elevation of blood urea nitrogen, hematocrit or blood glucose are early predictors of poor outcome. Furthermore, various scores can be used for risk assessment. Finally, the Atlanta classification can be used to classify the long-term severity of AP. Endoscopic retrograde cholangiography (ERC) with removal of the incarcerated gallstone should be performed in case of cholangitis and/or severe biliary AP. ERC is the only causal therapy in AP. Pain management and fluid resuscitation are the most important symptomatic measures. Early goal-directed fluid resuscitation using colloids might mitigate severe courses of AP. In the critical care setting, therapy should be guided by echocardiography and advanced hemodynamic monitoring. Antibiotic prophylaxis is likely advantageous in patients with severe AP. Furthermore, enteral nutrition should be provided as early as feasible. If these approaches are not possible or in case of complications (e.g., intra-abdominal compartment syndrome or bleeding), surgery is recommended ("step-up" approach).