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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024:10.1007/s11739-024-03666-9. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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2
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Subramani SS, Berg AC, Kral LA, Murad MH, Smith A, Phillips AE, Yadav D, Uc A, Imdad A. Analgesia for the treatment of acute pancreatitis: a protocol for a systematic review and network meta-analysis. BMJ Open 2024; 14:e081971. [PMID: 38740508 PMCID: PMC11097890 DOI: 10.1136/bmjopen-2023-081971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Gastrointestinal hospitalisations in the USA cause over US$130 billion in expenditures, and acute pancreatitis is a leading cause of these hospitalisations. Adequate pain control is one of the primary treatment goals for acute pancreatitis. Though opioids are commonly used for analgesia in these patients, there have been concerns about short-term and long-term side effects of using opioids. Recently, non-opioid medications have been studied to treat pain in patients with acute pancreatitis. This systematic review and network meta-analysis aims to assess the comparative efficacy of analgesic medication for non-severe, acute pancreatitis. METHODS AND ANALYSIS We will search multiple electronic databases for randomised controlled trials that study pain management in patients with non-severe, acute pancreatitis. The intervention will be any analgesic for acute pancreatitis in the hospital setting. The comparison group will be patients who received a placebo or other active interventions for pain management. The primary outcomes of interest include pain scores and the need for supplementary analgesia. The secondary outcomes will be serious adverse events, local complications, progression to severe pancreatitis, transfer to the intensive care unit, length of hospitalisation, time to start enteral feeds, 30-day all-cause mortality and Quality of Life Scale scores. If sufficient homogeneity exists among included studies, the findings will be pooled using a traditional pairwise and network meta-analysis. The risk of bias in randomised control trials will be evaluated using the Cochrane Risk of Bias Tool 2.0. The Grading of Recommendations, Assessment, Development, and Evaluation approach will be used to report the certainty of evidence. ETHICS AND DISSEMINATION This systematic review will not involve direct contact with human subjects. The findings of this review will be published in a peer-reviewed journal. They will give healthcare providers a better awareness of the optimal analgesic medication for pain treatment in non-severe, acute pancreatitis.
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Affiliation(s)
- Sriya S Subramani
- Stead Family Department of Pediatrics, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Alaina C Berg
- The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Lee A Kral
- Department of Anesthesia, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Mohammad Hassan Murad
- Department of Internal Medicine, Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abigail Smith
- Health Science Library, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Anna Evans Phillips
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Dhiraj Yadav
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg, Pittsburg, Pennsylvania, USA
| | - Aliye Uc
- Stead Family Department of Pediatrics, Radiation Oncology, Fraternal Order of Eagles Diabetes Research Center, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Aamer Imdad
- Stead Family Department of Pediatrics, Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, The University of Iowa, Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
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3
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Thierens NDE, Demir IE. How safe are opioids in the early phase of acute pancreatitis? United European Gastroenterol J 2024; 12:281-282. [PMID: 38334426 PMCID: PMC11017756 DOI: 10.1002/ueg2.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Affiliation(s)
- Naomi D. E. Thierens
- Department of Gastroenterology and HepatologyRadboudumcNijmegenNetherlands
- Department of Research and DevelopmentSt. Antonius ZiekenhuisNieuwegeinNetherlands
| | - Ihsan Ekin Demir
- Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenMunichGermany
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4
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Hussain A, Augustine SW, Pyakurel S, Vempalli H, Dabbara R, O'dare RA, Ayush, Varghese JJ, Inban P, Jayan M, Osigwe EC, Sunkara SM, Khan A. Acute Pancreatitis Induced by COVID-19 Vaccine: A Systematic Review. Cureus 2024; 16:e55426. [PMID: 38571842 PMCID: PMC10990070 DOI: 10.7759/cureus.55426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2024] [Indexed: 04/05/2024] Open
Abstract
Acute pancreatitis, marked by sudden inflammation of the pancreas, presents a complex spectrum of causative factors including gallstone obstruction, alcohol abuse, and viral infections. Recent studies have illuminated the emergence of vaccine-induced acute pancreatitis, notably associated with COVID-19 vaccinations, presenting diverse mechanisms ranging from direct viral-mediated injury to autoimmune reactions. Understanding this link is pivotal for public health, yet challenges persist in identifying and managing cases post-vaccination. Comprehensive literature reviews employing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement outline the potential pathways and mechanisms leading to vaccine-induced pancreatitis, emphasizing the need for deeper investigations into underlying health conditions and modifications to vaccine components. Notably, the rare occurrences of vaccine-induced pancreatitis extend beyond COVID-19 vaccines, with reports also documenting associations with measles, mumps, and rubella (MMR), human papillomavirus (HPV), and other viral vaccinations. Mechanistically, hypotheses such as molecular mimicry and immunologic injury have been proposed, necessitating ongoing vigilance and exploration. Regulatory agencies play a crucial role in monitoring and communicating vaccine safety concerns, emphasizing transparency to address potential risks and maintain public trust. Understanding and communicating these rare adverse events with transparency remain integral for informed vaccination policies and to allay concerns surrounding vaccine safety.
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Affiliation(s)
- Akbar Hussain
- Internal Medicine, Appalachian Regional Health, Harlan, USA
| | - Sana W Augustine
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Sandhya Pyakurel
- Internal Medicine, University of Science and Technology Chittagong, Chittagong, BGD
| | | | - Rishika Dabbara
- Internal Medicine, Kamineni Institute of Medical Sciences, Hyderabad, IND
| | - Rachel A O'dare
- Nursing, South University, Savannah, USA
- General Medicine, Medical University of Graz, Graz, AUT
| | - Ayush
- Internal Medicine, National Capital Region Institute of Medical Sciences, Meerut, IND
| | | | - Pugazhendi Inban
- General Medicine, Government Medical College, Omandurar Government Estate, Chennai, IND
| | - Malavika Jayan
- Internal Medicine, Bangalore Medical College and Research Institute, Bangalore, IND
| | | | | | - Aadil Khan
- Trauma Surgery, OSF Healthcare Hospital, University of Illinois College of Medicine, Peoria, USA
- Internal Medicine, Lala Lajpat Rai (LLR) Hospital, Kanpur, IND
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5
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Wu Y, Han C, Luo R, Cai W, Xia Q, Jiang R, Ferdek PE, Liu T, Huang W. Molecular mechanisms of pain in acute pancreatitis: recent basic research advances and therapeutic implications. Front Mol Neurosci 2023; 16:1331438. [PMID: 38188196 PMCID: PMC10771850 DOI: 10.3389/fnmol.2023.1331438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024] Open
Abstract
Although severe abdominal pain is the main symptom of acute pancreatitis, its mechanisms are poorly understood. An emerging body of literature evidence indicates that neurogenic inflammation might play a major role in modulating the perception of pain from the pancreas. Neurogenic inflammation is the result of a crosstalk between injured pancreatic tissue and activated neurons, which leads to an auto-amplification loop between inflammation and pain during the progression of acute pancreatitis. In this review, we summarize recent findings on the role of neuropeptides, ion channels, and the endocannabinoid system in acute pancreatitis-related pain. We also highlight potential therapeutic strategies that could be applied for managing severe pain in this disease.
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Affiliation(s)
- Yongzi Wu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Chenxia Han
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rong Luo
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenhao Cai
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Xia
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Ruotian Jiang
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Pawel E. Ferdek
- Department of Cell Biology, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland
| | - Tingting Liu
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
- Institutes for Systems Genetics and Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- West China Biobank, West China Hospital, Sichuan University, Chengdu, China
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Manrai M, Dawra S, Singh AK, Jha DK, Kochhar R. Controversies in the management of acute pancreatitis: An update. World J Clin Cases 2023; 11:2582-2603. [PMID: 37214572 PMCID: PMC10198120 DOI: 10.12998/wjcc.v11.i12.2582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/22/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
This review summarized the current controversies in the management of acute pancreatitis (AP). The controversies in management range from issues involving fluid resuscitation, nutrition, the role of antibiotics and antifungals, which analgesic to use, role of anticoagulation and intervention for complications in AP. The interventions vary from percutaneous drainage, endoscopy or surgery. Active research and emerging data are helping to formulate better guidelines. The available evidence favors crystalloids, although the choice and type of fluid resuscitation is an area of dynamic research. The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not. The empirical use of antibiotics and antifungals are gray zones, and more data is needed for conclusive guidelines. The choice of analgesic is being studied, and the recommendations are still evolving. The position of using anticoagulation is still awaiting consensus. The role of intervention is well established, although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery. It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.
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Affiliation(s)
- Manish Manrai
- Department of Internal Medicine, Armed Forces Medical College, Pune 411040, India
| | - Saurabh Dawra
- Department of Medicine and Gastroenterology, Command Hospital, Pune 411040, India
| | - Anupam K Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Daya Krishna Jha
- Department of Gastroenterology, Army Hospital (Research and Referral), New Delhi 11010, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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7
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Abstract
PURPOSE OF REVIEW This review provides insight into the recent advancements in the management of acute pancreatitis. RECENT FINDINGS Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. SUMMARY More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.
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Affiliation(s)
- Fons F. van den Berg
- Amsterdam UMC location University of Amsterdam, Medical Microbiology & Infection prevention
| | - Marja A. Boermeester
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9
- Amsterdam institute for Infection and Immunity
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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8
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Almulhim M, Almulihi QA, Almumtin HS, Alghanim MH, AlAbdulbaqi DA, Almulihi FAA. The Efficacy and Safety of Using Opioids in Acute Pancreatitis: an Update on Systematic Review and Meta-Analysis. Med Arch 2023; 77:281-287. [PMID: 37876565 PMCID: PMC10591254 DOI: 10.5455/medarh.2023.77.281-287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/05/2023] [Indexed: 10/26/2023] Open
Abstract
Background Most patients with acute pancreatitis (AP) suffer from abdominal pain that requires immediate pain relief, and there are various medication choices available, with opioids being the most prescribed analgesics. Objective Our objective is to compare the use of opioids with other medications in emergency settings for managing pain in patients with AP. Methods A systemic search was conducted in electronic databases (PubMed/Medline, Cochrane Library, Embase and Google Scholar) from inception to Feb 2023. All statistical analyses were conducted in Review Manager 5.4.1. The study's inclusion criteria was then selected. Only those Randomized Controlled Trials were involved that included patients having AP in an emergency setting. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the Odds Ratio (OR) and Mean Difference (MD) along with the corresponding 95% confidence interval (CI). Narrative analysis was conducted for those variables which did not have sufficient data be included in the quantitative analysis. Results We include eight Randomized Controlled Trials in our study. The Pooled result showed non-significant differences in adverse effects between the two interventions (OR 1.42 [95% CI 0.62, 3.23]; p value= 0.40; I2= 20%). While overall, significantly additional drugs were used in the control group (OR 0.22 [95% CI 0.06, 0.85]; p value= 0.03; I2= 72%). Pain score and severity levels were also analyzed. We used a narrative approach to analyze the length of stay, mean time to reach significant decrease in pain, and mortality, which were all non-conclusive. We also narratively assessed the Pediatric population. Conclusion Opioids do not provide significant superiority over other medications and should be avoided due to their addictive nature.
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Affiliation(s)
- Mohamed Almulhim
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Qasem Ahmed Almulihi
- Department of Emergency Medicine, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
- Department, King Fahad University Hospital, Al Khobar, Saudi Arabia
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Chan KS, Shelat VG. Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies. World J Gastrointest Surg 2022; 14:1179-1197. [PMID: 36504520 PMCID: PMC9727576 DOI: 10.4240/wjgs.v14.i11.1179] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/08/2022] [Accepted: 10/25/2022] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
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Szatmary P, Grammatikopoulos T, Cai W, Huang W, Mukherjee R, Halloran C, Beyer G, Sutton R. Acute Pancreatitis: Diagnosis and Treatment. Drugs 2022; 82:1251-1276. [PMID: 36074322 PMCID: PMC9454414 DOI: 10.1007/s40265-022-01766-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/11/2022]
Abstract
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
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Affiliation(s)
- Peter Szatmary
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Wenhao Cai
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- West China Centre of Excellence for Pancreatitis and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Department of Molecular Physiology and Cell Signalling, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool , UK
| | - Chris Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Georg Beyer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Department of Molecular and Clinical Cancer Medicine, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK. .,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
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11
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Chen Z, Jiang K, Liu F, Zhu P, Cai F, He Y, Jin T, Lin Z, Li Q, Hu C, Tan Q, Yang X, Guo J, Huang W, Deng L, Xia Q. Safety and efficacy of intravenous hydromorphone patient-controlled analgesia versus intramuscular pethidine in acute pancreatitis: An open-label, randomized controlled trial. Front Pharmacol 2022; 13:962671. [PMID: 35991892 PMCID: PMC9387897 DOI: 10.3389/fphar.2022.962671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Hydromorphone patient-controlled analgesia (PCA) provides satisfactory postoperative pain therapy, but its effect has not been assessed in acute pancreatitis (AP).Aim: To assess the safety and efficacy of intravenous hydromorphone PCA for pain relief in AP.Methods: This open-label trial included AP patients admitted within 72 h of symptom onset, aged 18–70 years old, and with Visual Analog Scale (VAS) for pain intensity ≥5. They were randomized to receive intravenous hydromorphone PCA (0.05 mg/h with 0.2 mg on-demand) or intramuscular pethidine (50 mg as required) for three consecutive days. Intramuscular dezocine (5 mg on demand) was the rescue analgesia. The primary outcome was the change of VAS score recorded every 4 h for 3 days. Interim analysis was conducted by an Independent Data and Safety Monitoring Committee (IDSMC).Results: From 26 July 2019 to 15 January 2020, 77 patients were eligible for the intention-to-treat analysis in the interim analysis (39 in the hydromorphone group and 38 in the pethidine group). Baseline parameters were comparable between groups. No difference in VAS between the two groups was found. Hydromorphone PCA was associated with higher moderately severe to severe cases (82.1% vs. 55.3%, p = 0.011), acute peripancreatic fluid collections (53.9% vs. 28.9%, p = 0.027), more cumulative opioid consumption (median 46.7 vs. 5 mg, p < 0.001), higher analgesia costs (median 85.5 vs. 0.5 $, p < 0.001) and hospitalization costs (median 3,778 vs. 2,273 $, p = 0.007), and more adverse events (20.5% vs. 2.6%, p = 0.087). The per-protocol analysis did not change the results. Although a sample size of 122 patients was planned, the IDSMC halted further recruitment as disease worsening or worse clinical outcomes between the groups in the interim analysis.Conclusion: Hydromorphone PCA was not superior to pethidine in relieving pain in AP patients and might have worse clinical outcomes. Therefore, its use is not recommended.Clinical Trial Registration: Chictr.org.cn. ChiCTR1900025971
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Affiliation(s)
- Zhiyao Chen
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Jiang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Zhu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Cai
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yanqiu He
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Jin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ziqi Lin
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Cheng Hu
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qingyuan Tan
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaonan Yang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jia Guo
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Lihui Deng
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
| | - Qing Xia
- Pancreatitis Center, Center of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Huang, ; Lihui Deng, ; Qing Xia,
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Nair A, Tiwary MK, Seelam S, Kothapalli KK, Pulipaka K. Efficacy and Safety of Thoracic Epidural Analgesia in Patients With Acute Pancreatitis: A Narrative Review. Cureus 2022; 14:e23234. [PMID: 35449658 PMCID: PMC9012692 DOI: 10.7759/cureus.23234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/09/2022] Open
Abstract
Patients admitted to the intensive care unit with moderate to severe acute pancreatitis carry significant morbidity and mortality. A few unfortunate patients in whom the initial line of treatment fails to show clinical improvement develop multiorgan dysfunction involving lungs (adult respiratory distress syndrome), renal failure, intra-abdominal infections, sepsis, and septic shock, which ultimately leads to prolonged hospitalization and a substantial cost of treatment. The acute abdominal pain experienced by these patients is excruciating and requires multimodal analgesia. Continuous epidural analgesia has been found to provide good quality, opioid-sparing analgesia in these patients. A few studies have also demonstrated that segmental sympathectomy resulting from epidural blockade could lead to lowering of serum amylase and lipase levels improve paralytic ileus, and thus hastens the process of recovery. The present paper aims to discuss the advantages of continuous epidural analgesia in patients with acute pancreatitis of varying severity and to review the existing literature using specific keywords.
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