Acute pancreatitis is the one of the most common gastroenterological diseases causing hospital admission, ranking number 3 on the list, and is among the top 5 most expensive gastric ailments to treat, Timothy Gardner, MD, told the attendees at the postgraduate course of the American College of Gastroenterology on October 23.

Dr Gardner is professor of medicine and director of the Pancreatic Disorders program at Dartmouth-Hitchcock Medical Center in Dartmouth, New Hampshire.

The greatest difficulty in treating acute pancreatitis, he said, is that “there still are no approved therapies for acute pancreatitis, which means patients are still going to die from this.”

The first step in dealing with acute pancreatitis, he explained, is to make sure the patient does not have chronic pancreatitis, obtaining cross-sectional imaging and other testing to help distinguish the conditions.

Dr Gardner explained that while once the primary etiology for acute pancreatitis was “idiopathic,” this disorder is more commonly attributed today to biliary disease. Other common causes include alcohol abuse and obstruction.

“It’s widely variable how much alcohol it takes to cause acute pancreatitis,” he said, noting that in most cases the cause is serial alcohol use over several years. In biliary disease, Dr Gardner pointed out, “it is really important to remember microlithiasis—think of grains of sand, not larger stones.” Laparoscopic cholecystectomy can be effective in preventing recurrent bouts of acute pancreatities; in one study, half of patients had this procedure resulting in a 50% reduction in recurrence.

Obstructive causes for acute pancreatitis may include adenocarcinoma, pancreatic cysts, and ductal disruptions, which Dr Gardner noted as “very underrecognized.” Congenital defects may contribute to pancreatitis, while hypertriglyceridemia “can be a result or a cause.” While a number of drugs may cause acute pancreatitis, Class 1 drugs are the most often implicated.

“All patients with recurrent idiopathic acute pancreatitis should be evaluated” for genetic factors, especially younger individuals, he said. Type 2 autoimmune pancreatitis—which, Dr Gardner explained, “is totally different from type 1,” is very closely associated with inflammatory bowel disease.

Optimal management of acute pancreatitis requires adequate fluid resuscitation with lactated Ringer’s, which has been shown to reduces systemic inflammation more effectively compared with saline. “You have to watch closely for over-resuscitation with these patients,” Dr Gardner cautioned.

He further stated that antibiotics are of no value in treating this condition. However, medical therapy can be successful in the treatment of infected pancreatic necrosis. 

Dr Gardner stressed the importance of nutritional support for these patients. “It’s very important to feed them enterally and early. The whole idea of ‘resting the pancreas’ is 1970’s medicine. We should use the gut as early as possible.”

There is hope for better therapy in the future, he concluded. “There are now 52 clinical trials for acute pancreatitis that are recruiting participants, so we should see some new alternatives for treating this disease in the future.”

--Rebecca Mashaw

Gardner, TB. Common and unusual causes and optimal management of acute pancreatitis. Presented at the American College of Gastroenterology postgraduate course. October 23, 2021.