Key messages

• Basic medical management includes intensive care support of failing organs, nasogastric suction, analgesia, antibiotic prophylaxis, and nutritional support. Bacterial translocation and subsequent pancreatic infection may justify early jejunal feeding and selective gut decontamination.

• The conservative therapeutic approach favors non-surgical removal of toxic substances released by the inflammatory necrotizing process, relying upon peritoneal lavage and drainage of thoracic lymph. Early endoscopic dislodgement is advocated for impacted ampullary stones and worsening remote organ failure or acute cholangitis. Surgery is delayed until massive hemorrhage, complicated pseudocyst, or bacterial contamination of necrosis are demonstrated. Careful serial monitoring of pancreatic necrosis is mandatory for early identification.

• In selected cases with local complications, particularly fully liquified collections (e.g. pancreatic abscess and infected pseudocyst), percutaneous drainage is a valid alternative to surgery.

• Most therapeutic modalities are still directed towards the complications. Future therapies should aim at early reduction of the volume of regional necrosis by blocking premature activation of pancreatic proenzymes, enhancing the glandular microcirculation, and modulating mediators of the inflammatory reaction.

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