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Intravascular volume depletion secondary to leakage of fluids in the pancreatic bed and ileus with fluid-filled loops of bowel may result in prerenal azotemia and even acute tubular necrosis without overt shock This usually occurs within 24 hours of the onset of acute pancreatitis and lasts 8 9 days Some patients require peritoneal dialysis or hemodialysis Sterile or infected necrotizing pancreatitis may complicate the course of 5 10% of cases and accounts for most of the deaths The risk of infection does not correlate with the extent of necrosis Pancreatic necrosis is often associated with fever, leukocytosis, and, in some cases, shock and is associated with organ failure (eg, pulmonary, renal, gastrointestinal bleeding) in 50% of cases Because infected pancreatic necrosis is almost always an indication for operative treatment, fine-needle aspiration of necrotic tissue under CT guidance should be performed (if necessary, repeatedly) for Gram stain and culture A serious complication of acute pancreatitis is acute respiratory distress syndrome (ARDS); cardiac dysfunction may be superimposed It usually occurs 3 7 days after the onset of pancreatitis in patients who have required large volumes of fluid and colloid to maintain blood pressure and urinary output Most patients with ARDS require assisted respiration with positive end-expiratory pressure Pancreatic abscess is a suppurative process characterized by rising fever, leukocytosis, and localized tenderness and epigastric mass usually 6 or more weeks into the course of
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given intravenously if there is evidence of hypocalcemia with tetany Infusions of fresh frozen plasma or serum albumin may be necessary in patients with coagulopathy or hypoalbuminemia With colloid solutions, there may be an increased risk of developing ARDS If shock persists after adequate volume replacement (including packed red cells), pressors may be required For the patient requiring a large volume of parenteral fluids, central venous pressure and blood gases should be monitored at regular intervals Parenteral nutrition (including lipids) should be considered in patients who have severe pancreatitis and ileus and will be without oral nutrition for at least 7 10 days Enteral nutrition via a nasogastric or nasojejunal feeding tube is preferable but may not be tolerated in some patients with an ileus Imipenem (500 mg every 8 hours intravenously) and possibly cefuroxime (15 g intravenously three times daily, then 250 mg orally twice daily) administered for up to 14 days to patients with sterile pancreatic necrosis appear to reduce the risk of pancreatic infection and mortality, but the combination of ciprofloxacin and metronidazole does not appear to reduce the frequency of infected necrosis, multiorgan failure, or mortality The routine use of antibiotics in patients with pancreatic necrosis is still controversial and is not indicated in those with < 30% pancreatic necrosis The role of intravenous somatostatin in severe acute pancreatitis is uncertain, but octreotide is thought to have no benefit There is conflicting evidence as to whether the risk of pancreatitis after ERCP can be reduced by the administration of somatostatin or gabexate mesilate, a protease inhibitor Allopurinol and ulinastatin, another protease inhibitor, have been reported to reduce the frequency of post-ERCP pancreatitis Lexipafant, an antagonist of platelet-activating factor, appears to be of no benefit
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improve survival in severe acute pancreatitis, in part because the risk of late septic complications is not reduced The development of a pancreatic abscess is an indication for prompt percutaneous or surgical drainage Chronic pseudocysts require endoscopic, percutaneous catheter, or surgical drainage when infected or associated with persisting pain, pancreatitis, or common duct obstruction For pancreatic infections, imipenem, 500 mg every 8 hours intravenously, is a good choice of antibiotic because it achieves bactericidal levels in pancreatic tissue for most causative organisms Pancreatic duct leaks and fistulas may require endoscopic or surgical therapy
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