Acute pancreatitis and octreotide

Surgical complications of selected gastrointestinal emergencies: pitfalls in management of the acute abdomen

Complaints referable to the abdomen are common emergency department presentations. Many of these conditions prove to be benign and self-limited, whereas others are potentially catastrophic. Because serious and benign intra-abdominal conditions share many relatively nonspecific symptoms, it is often difficult to identify patients who have life-threatening problems early in the course of their disease. Apart from relieving the patient's symptoms, the emergency physician's primary role is to detect and stabilize life-threatening conditions in a rapid and cost-effective manner.

Evaluation of factors that have reduced mortality from acute pancreatitis over the past 20 years

BACKGROUND

The mortality associated with acute pancreatitis varies markedly in different studies, with most frequently reported mortality rates of 10% to 15% for all cases and 15% to 90% for attacks regarded as "severe." More recently, various centers have recorded lower mortality rates of 4% to 7% for all attacks of acute pancreatitis and 20% to 50% for those regarded as severe.

GOALS

To investigate whether there has been a reduction in mortality associated with acute pancreatitis over the past 20 years and the reasons for this reduction.

STUDY

Intended as a review, this study included the authors' 20-year prospective assessment of mortality as it relates to the severity of the disease, complications, and current therapy. For the mortality results, the study was divided into four 4-year periods from 1977 to 1998 and the past 3 years (i.e., 1998-2001). For comparison, the mortality figures from some other large studies are presented.

RESULTS

This study showed that the initial reduction in mortality related to acute pancreatitis coincided with the recognition and application of the signs of severity, either Ranson's prognostic signs or Bank's clinical criteria. These signs dictated admission to intensive care unit (ICU) therapy, the intensity of ICU monitoring, and the importance of organ-specific emergent therapy. Further mortality reduction in the 1990s could be attributed to either a more select study sample or earlier and more selective endoscopic or surgical debridement of infected tissue, endoscopic cyst drainage, and angiographic control of gastrointestinal bleeding. Improved nutritional support by jejunal feeding, earlier use of antibiotic therapy, gut sterilization, early endoscopic retrograde cholangiopancreatography for common bile duct stones and necrosectomy for noninfected necrosis have reduced the overall mortality associated with acute pancreatitis to a mean of 5% (range, 3.8-7%) for all cases and 20% (range, 15-25%) for severe cases. However, it is clear that the greater the number of signs denoting severity of organ failure, the higher the mortality.

CONCLUSIONS

There has been considerable reduction in the mortality associated with acute pancreatitis over the past 20 years. The reasons are multifactorial, but recognition of severity signs, early implementation of organ-specific therapy, and newer endoscopic, surgical, and angiographic therapy for infection cyst and bleeding appear to have been the major factors in reducing mortality.