Question 111

METHODS OF CONSERVATIVE
TREATMENT OF ACUTE PANCREATITIS.
 CONSERVATIVE THERAPY (1)
For acute edematous pancreatitis

1. It is expedient to administer fasting in the first 1–3 days of the disease (to provide physiological
rest of the gland) and intake of alkaline solutions every 2 hours (for example, sodium bicarbonate —
0.5–0.6 mg for a glass of water or mineral water “Borzhomi”).

2. Aspiration of the gastric contents through the probe to prevent ingress of the hydrochloric acid
into the duodenum.

3. Analgesics — to fight with pain syndrome (preferably nonnarcotics, in some cases — tramal,
tramadol, moradol).

4. Myotripic spasmolytics (no-spa, papaverin, buscopan, galidor) — to restore outflow of the

pancreatic juice.

5. M-choline blockers (atropin, platiphilin, gastrocepin) — to suppress secretion of the pancreas and
remove spasm of its ducts.

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6. Infusion therapy (colloids, crystalloids), their volume is determined by the clinical
situation; the main task of the infusion therapy in this case is fight with endogenic
intoxication.

7. Antioxidants (ascorbinic acid, ceruloplasmin, tocoferol) — to reduce peroxide oxidation of

lipids.

8. In gastrogenic pancreatites — H2-blockers, antacides, sucralfat (decrease of gastric juice

secretion to prevent pH reduction in the duodenum).

Duration of hospital treatment is 3–7 days.

Requirements to treatment results: control of the pain syndrome, absence of changes in

blood count indicating the inflammatory process, normalization of the body temperature.

 CONSERVATIVE THERAPY (3)

For destructive pancreatitis

I. In I and II periods (the period of hemodynamic disorders and pancreatogenic shock and the period of polyorganic insufficiency)
Basic therapy should be started immediately after establishment of the diagnosis of “severe pancreatitis” (within 2 hours of
hospitalization):

1. Fasting and intake of alkaline solutions for 3 days and longer.

2. Decompression of the stomach with the probe with periodic aspiration of the gastric contents.

3. Suppression of the external secretory activity of the pancreas for correction of release of the pancreatic enzymes in blood and
adjacent cavities and tissues is one of the main components of intensive treatment of patients with acute disease and damage of this
organ. Suppression of the external secretory activity may be achieved by several ways:

— introduction of antienzymes in blood or locally, first of all antiproteases (contrical, aprotinin, trasilol, gordox, pantripin, 2-
macroglobulin);

— chemical inhibition of pathological hyperactivity of pancretocytes (cytostatics-antimetabolites: 5-fluorouracil, flourafur,

ribonuclease, etc.);

— application of regulatory peptides (somatostatin, calcitonin);

— physical methods with application of intragastric or external (mostly zonal) therapeutic hypothermy.

 CONSERVATIVE THERAPY (4)

At present there is a method of choice consisting in application of block- ers of the pancreas
secretion of the regulatory peptide group, sometimes artificial pancreatic hypothermy is made
along with them. Reserve methods (when regulatory peptides and hypothermy are ineffective) are
cytostatic drugs. Nowadays inhibitors of proteolytic enzymes of the antiprotease group are used
only in treatment of DIC-syndrome (it often develops in acute pancreatitis).

Blockers of the pancreas secretion:

a) somatostatin (sandostatin R (NOVARTIS) 0.1 mg 3 times a day sub- cutaneously for 5–7 days;

b) calcitonin (myacalcic R (NOVARTIS) 300 IU/24 hr i/v for 6 days;

c) 5-lay-encephalin (dalargin) 10 mg i/v dropwise, then 4 mg 3 times a day/i.m.

Blockers of the pancreas secretion should be administered only in the first 5–7 days of the disease,
and drugs of somastatin — in development of arrosive bleedings and fistula (pancreatic, intestinal).

 CONSERVATIVE THERAPY (5)

4. Cytokine blockade (pentoxiphilin 20 ml a day i/v dropwise for 5–7 days).

5. Antioxidants:

— ascorbinic acid — 5% solution 10–20 ml a day for 5 days.

— α-tocoferol 2 ml a day for 5 days.

— ceruloplasmin 100 mg a day for 5–7 days (as a stimulator of haemo- poiesis may be used in anemia in patients with
purulent-necrotic complica- tions).

6. Analgesics for controling pain syndrome: nonnarcotic (baralgin, keta- nov), narcotic (except morphine, which causes spasm
of the Oddi’s sphinc- ter and may aggravate the patient’s state), peridural anesthesia or other types of blockade with local
anesthetics (paranephral blockade, blockade of the round hepatic ligament, sacrospinal blockade, intracutaneous blockade of
the abdominal plexus by Capisse).

7. Spasmolytics for facilitation of pancreas secretion outflow: myo- tropic (no-spa, papaverin, buscopan, galidor), M-
cholinoblockers (atro- pin, platiphilin, gastroceptin), the latter also reduce secretion of the pan- creatic juice.

8. Stimulators of the intestinal motility — fight with intestinal paresis: ubretid 0.5 mg, repeated introduction not earlier than in
24 hours; benzo- hexamenthonium 2.5% 0.5 ml twice a day; peridural anesthesia.

 CONSERVATIVE THERAPY (6)

9. Infusion therapy under the control of laboratory indices (the volume depends on the
clinical situation; colloids are more preferable than isotonic solutions of crystalloids).
The aim is to fight with hypovolemia, electrolyte disorders and acid-alkaline disbalance,
disintoxication, sometimes — parenteral feeding. At the initial stages of the disease
when there are signs of massive early dehydration, the infusion therapy should be
intensive, with introduction of up to 65–100 ml of solution per 1 kg of the body weight
per day, the ratio of colloids and crystalloids should be 1:1.

In reduction of the dehydration degree, the volume of the introduced liquid is

decreased and the amount of colloids in it increases. Correction of the acid-alkaline
balance is required. For detoxication, the infusion therapy should contain such drugs as
neohaemodesis, gelatinol as well as a method of forced diuresis. For parenteral feeding
the patient is an intravenously introduced solution of aminoacids — aminosol or alvesin
by 500 ml dropwise from the 2nd day of fasting.

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10. Physical methods of detoxication. In emergency pancreotology there are widely
used plasmopheresis, haemo- and plasmosorption, external introduction of lymph
and lymphosorption, peritoneal irrigation and peritoneal dialysis. Therapeutic
methods that replace and model the processes of biotransformation of endogenic
toxins are less developed and introduced into the clinical practice of management of
patients with acute pancreatitis. They may include isolated homo- and xenoorgans
(the liver, the kidneys, the spleen). Therapeutic methods of active detoxication also
include methods aimed at direct change of the internal medium by the so-called
hemocorrection. Hemocorrection is achieved at the expense of oxige- nation,
magnetic treatment or irradiation and photomodification of blood that are made both
extracorporally, after blood taking and intracorporally, by the intravascular way.
 CONSERVATIVE THERAPY (8)
11. Treatment of the DIC-syndrome — heparinotherapy (10–20 thousand U per day sub- cutaneously or i/v), inhibitors of
proteases i/v (see above) in combination with rheopolyglucine, nicotinic acid, euphyllin (10 ml, 2.4% solution i/v
slowly in 10–20 ml of the isotonic solution).

12. Antibioticotherapy in acute pancreatitis is aimed at prevention of development of purulent-septic complications:

— carbopenems (tienam 500 mg 3–4 times a day i/v dropwise; meronem 500–1,000 mg i/v dropwise once a day).

— fluochinols (ciprofloxacin 500–750 mg twice a day, ofloxacin (Tariv- id) 400–800 mg twice a day i/v dropwise,
pefloxacin (abactal) 400 mg twice a day i/v dropwise;

— cephalosporins of II–IV generation — cephtriaxon, cephobid, cepho- taxim, cephtisoxim;

— synthetic penicillins — piperacillin, meslocillin.

All antibiotics (except carbopenems) should be combined with antianaer- obic drugs that are introduced parenterally
(metragil, trichopol).

The course of antibioticotherapy of not less than 14 days is always complemented by antimycotic therapy (ketoconasol
(nisoral) 200 mg per day, fluconasol (diflucan) 50–400 mg per day.

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13. Prevention of erosive-ulcerous affections of GIT, as well as fight with oxidation of the duodenal contents which is a stimulator
of the pancreatic secretion (H2-blockers, antacids, inhibitors of H+, sucralfate).

14. Prevention of translocation of the intestinal microflora (i. e. barrier dysfunction of the intestinal wall):

— detoxication (intraintestinal lavage, enterosorption);

— correction of metabolic disorders and restoration of the barrier func- tion of the intestine (glutamin, arginin, antioxidants);

— immunocorrection (ω–3, ω–6, polyunsaturated fatty acids “Tecom”, arginin, glutamin);

— enteral feeding as early as possible (insertion of the probe in the initial section of the small intestine intraoperatively (when the
patient has been operated on) or endoscopically;

— selective decontamination of the intestine (polymyxin, norfloxacin, amfotericin B).

15. Correction of hyperlipidimia (lipostabil 10–20 ml a day i/v).

16. Hepatoprotectors: essentiale, carsil, legalon (the former is not ad- ministered in cholestasis, the latter two ones — in chronic
active hepatitis). In presence of affection of target-organs (respiratory-distress syndrome,

acute renal failure, hepatic insufficiency therapy is polysyndromic).

 CONSERVATIVE THERAPY (10)

II. Treatment in the III period (dystrophic and purulent-necrotic complications) in formation of the pancreatic
infiltrate.

Basic therapy:

— antibioticotherapy (antibiotics of choice are given above);

— antiacidic therapy: antacids, sucralfate, H2-blockers;

— immunomodulating therapy (sodium nucleinate, timalin, T-activin,

levamisol);

— analgesics, spasmolytics, antiemetics;

— infusion therapy (if necessary);

— parenteral feeding (if necessary).

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