Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 536

The majority of patients with pancreatitis present with mild disease and require only observation, IV fluids, and symptom control with analgesia and anti‐emetics. Antibiotics are rarely indicated. Patients with a BISAP score greater than 2 should generally be triaged to an intensive care unit for more careful monitoring.

Nutrition is another key therapeutic component. As opposed to delayed nutrition, early initiation of nutrition has shown improved outcomes, preferably using oral feeding.¹¹ In patients with mild pancreatitis, early initiation of a low‐fat diet (versus a clear liquid diet) has been shown to reduce length of hospital stay. Patients with moderate or severe pancreatitis may not be in a clinical condition to tolerate oral feeding within 48–72 hours, so enteral feeding using a nasogastric or nasojejunal tube is recommended and should be initiated within 72 hours when possible. Several randomized controlled trials and meta‐analyses report no differences in pre‐pyloric versus post‐pyloric feeding.¹² Parenteral nutrition is considered the last option for nutrition if caloric goals cannot be met through enteral means. Compared to enteral feeding, parenteral nutrition is associated with a significantly higher risk of infection in this patient population, including bacteraemia and infected necrosis.

Routine antibiotic therapy in severe acute pancreatitis is not recommended unless there is evidence of infected necrosis or persistent clinical instability concerning sepsis.¹³ In patients with bile duct stones, endoscopic duct clearance by ERCP is recommended, although this need not be performed urgently except in cholangitic patients. There is now clear data that patients with gallstones who develop mild acute pancreatitis should undergo cholecystectomy during their index admission to reduce the likelihood of repeated attacks and subsequent complications.¹⁴

Acute pancreatic fluid collections and pancreatic necrosis, which may develop in the first four weeks, are generally best managed conservatively. If these collections persist beyond four weeks, they can become walled off as pseudocysts (fluid) or walled‐off pancreatic necrosis (solid debris) (see Figure 21.1). Walled‐off collections can be drained/debrided endoscopically if symptomatic using a variety of well‐supported techniques. Radiologic drainage or surgery should be uncommonly required in the modern era. In particular, surgery performed for pancreatic necrosis is associated with high morbidity and mortality and should be performed only by surgical teams with strong experience in this area.

Figure 21.1 Acute necrotizing pancreatitis, with a bilobed walled‐off necrosis occupying the body and tail of the pancreas.