Antibiotic prophylaxis is another area of acute pancreatitis that is under scrutiny. Most experts agree that in mild pancreatitis, there is no indication for antibiotics.4,7 Severe acute pancreatitis offers more of a challenge. In the emergency department, it is often impossible to distinguish SIRS secondary to acute pancreatitis from that caused by bacterial sepsis.
Explore This IssueACEP News: Vol 29 – No 12 – December 2010
In patients with acute abdominal pain, fever, and systemic toxicity, it is reasonable to initiate broad-spectrum antibiotics pending a complete infectious work-up, which may include eventual fine-needle aspiration of areas of pancreatic necrosis to distinguish sterile from infected necrosis.1,3 Once infectious etiologies including pancreatic abscess and pseudocyst are ruled out, antibiotics should be discontinued.1 Recommended antibiotics include carbapenems,2 which have high pancreatic tissue penetration, or the combination of ciprofloxacin and metronidazole.1,7
Emergency physicians should be familiar with the optimal timing of ERCP in the evaluation of acute pancreatitis. In patients with presumed biliary pancreatitis, the presence of choledocholithiasis or cholangitis mandates an urgent ERCP (within 24 hours of admission).1,7 Unrelieved obstruction can lead to worsening pancreatitis.2,4
Acute pancreatitis remains a disease with significant morbidity and mortality. The emergency physician’s role in prompt recognition, assessment of severity, and initiation of supportive care is central to the treatment of this disease.
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- Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. May 18 2006;354(20):2142-50.
- Lowenfels AB, Maisonneuve P, Sullivan T. The changing character of acute pancreatitis: epidemiology, etiology, and prognosis. Curr Gastroenterol Rep. Apr 2009;11(2):97-103.
- Yadav D, Whitcomb DC. The role of alcohol and smoking in pancreatitis. Nat Rev Gastroenterol Hepatol. Mar 2010;7(3):131-45.
- Stevens T, Parsi MA, Walsh RM. Acute pancreatitis: problems in adherence to guidelines. Cleve Clin J Med. Dec 2009;76(12):697-704.
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- Sekimoto M, Takada T, Kawarada Y, et al. JPN guidelines for the management of acute pancreatitis: epidemiology, etiology, natural history, and outcome predictors in acute pancreatitis. J Hepatobiliary Pancreat Surg. 2006;13(1):10-24.
- Shah AM, Eddi R, Kothari ST, et al. Acute pancreatitis with normal serum lipase: a case series. JOP. 2010;11(4):369-72.
- Andris A. Pancreatitis: understanding the disease and implications for care. AACN Adv Crit Care. Apr-Jun 2010;21(2):195-204.
- Marx JA, Hockberger RS, Walls RM, et al. Rosen’s emergency medicine: concepts and clinical practice. 7th ed. Philadelphia: Mosby/Elsevier; 2010.
- UK guidelines for the management of acute pancreatitis. Gut. May 2005;54 (Suppl 3):iii1-9.
- Smith RC, Southwell-Keely J, Chesher D. Should serum pancreatic lipase replace serum amylase as a biomarker of acute pancreatitis? ANZ J Surg. Jun 2005;75(6):399-404.
- Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol. Jun 2002;97(6):1309-18.
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- Chen YT, Chen CC, Wang SS, et al. Rapid urinary trypsinogen-2 test strip in the diagnosis of acute pancreatitis. Pancreas. Apr 2005;30(3):243-7.
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- Brown A, Baillargeon JD, Hughes MD, Banks PA. Can fluid resuscitation prevent pancreatic necrosis in severe acute pancreatitis? Pancreatology. 2002;2(2):104-7.
- Khan Z, Vlodov J, Horovitz J, et al. Urinary trypsinogen activation peptide is more accurate than hematocrit in determining severity in patients with acute pancreatitis: a prospective study. Am J Gastroenterol. Aug 2002;97(8):1973-7.
- Singh VK, Wu BU, Bollen TL, et al. A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis. Am J Gastroenterol. Apr 2009;104(4):966-71.
- Gardner TB, Vege SS, Pearson RK, Chari ST. Fluid resuscitation in acute pancreatitis. Clin Gastroenterol Hepatol. Oct 2008;6(10):1070-6.
- Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology. May 2007;132(5):2022-44.
- Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol. Apr 2001;96(4):1266-72.