Acute pancreatitis: In the older patient
Authors: Malik, N. and Allen, S.C.
Journal: CME Geriatric Medicine
The spectrum of acute pancreatitis (AP) ranges from a mild spontaneously resolving disorder to severe disease with a high mortality. The extent of pancreatic necrosis and bacterial superinfection are the most important factors related to mortality.1 The incidence of this type of AP varies from 4-18% and it has a reported mortality of 10-40%.1 The apparent higher mortality of acute pancreatitis in elderly patients may be due to the presence of concomitant cardiopulmonary diseases and reduced physiological reserves due to natural ageing processes.2 During the past few years a significant reduction in mortality rates has been observed due to improvements in ICU care, radiological diagnostic methods, standardization of operative indications and surgical techniques, as well as introduction of prophylactic antimicrobial therapy.1 Contrast-enhanced abdominal CT is the gold standard for the diagnosis of pancreatic necrosis with an accuracy of more than 90%.3 The presence of radiologically detected pancreatic necrosis markedly increases the morbidity and mortality associated with AP.3 The cornerstones of treatment of patients with AP include early aggressive fluid resuscitation, intensive care with close haemodynamic monitoring, support of multi-system organ failure, antibiotic prophylaxis, and surgery in selected cases with pancreatic necrosis or deterioration of patient’s condition in spite of maximal conservative therapy.4 The most important diagnostic step in the management of patients with acute necrotizing pancreatitis is discrimination between interstitial-oedematous and necrotizing pancreatitis.5 In recent years, the treatment of these patients has shifted from early surgical debridement (necrosectomy) to aggressive intensive medical care, with specific criteria for operative and non-operative intervention.5 Early endoscopic removal of common bile duct stones should be considered in cases with biliary AP.6
Preferred by: Stephen Allen