New roadmap for treatment of acute pancreatitis

Acute pancreatitis is not uncommon. It has an annual global incidence rate of 4.9–73.4 cases per 100,000 people, with Australia sitting at the higher end of the spectrum.
 
For some, it has the potential of being life-threatening and, to date, there is still no specific treatment.
 
But there is hope according to a new roadmap published in the British Society of Gastroenterology’s journal Gut.
 
Developed by an international team of experts, it pinpoints the two most significant thresholds of the disease that could serve as a starting point for targeting treatment strategies.
 
Lead author Dr Savio Barreto, a gastrointestinal and hepato-pancreato-biliary surgeon and researcher from Flinders University, told newsGP the first threshold is when the patient is first exposed to some damage.
 
‘It could be alcohol, it could be gallstones, or it could be a mix of the two … and it can take the pancreas to a point that then starts an inflammatory cascade that’s associated with severe disease,’ he said. 
 
‘The second threshold is where the patient then decides I’ve got severe pain in my abdomen, I’m going to call the ambulance to go into hospital.
 
‘But 70% of patients who come to hospital actually have a mild form of the disease. So if you can start to focus on targeting treatments to this group, they won’t [necessarily] go down the terrible path of severe disease.’
 
While a specific treatment has yet to be discovered, Dr Barreto says much can be done to change the course of disease by using existing research and guidelines; but he also believes there needs to be a ‘mindset change’ and hopes the research will contribute.
 
‘This study presents the most updated and comprehensive pathogenesis of acute pancreatitis. But everything that we’re saying in this paper is not new,’ he said.
 
‘Fluid resuscitation in acute pancreatitis is something that we’ve known for years – it’s part of all the guidelines. But sadly, when patients reach emergency departments and are even diagnosed with acute pancreatitis, they don’t always receive the necessary amount of intravenous (IV) fluids they require. 
 
‘So a simple thing to do – yes, it’s not a magic bullet – just give the patient fluids, and that may prevent them progressing to the severe stage of organ damage, which is associated with risk of death.
 
‘So it’s changing the mindset of the way people look at acute pancreatitis. Rather than saying I cannot do anything about it once the wheels have been set into motion, [say] “No, we have an opportunity”.’
 
Dr Barreto says this is also relevant to GPs, as they are often the ‘first port of call’ for patients with symptoms of acute pancreatitis. 
 
‘In the non-acute setting, the patient may come in with gallstones, for instance. Small gallstones worry me more than big gallstones because the small ones can travel down the bile passage (bile duct) more easily and cause pancreatitis,’ he said.
 
‘So those are the ones that should be referred early on to a surgeon for consideration of a cholecystectomy.
 
‘In the acute setting, where a patient comes in saying “I have severe upper abdominal pain, it’s going to my back and I’m very nauseated”, the first step is to recognise that this patient could have acute pancreatitis based on the symptom cluster and consider transferring them to an emergency department early, rather than trying to just treat them with pain relief.’
 
However, for GPs in rural and remote areas, where there may be a delay in transferring the patient, Dr Barreto says more can be done in the interim to support the patient.
 
‘Say I’m a GP in the country and I know this is acute pancreatitis and I have to transfer this patient three or four hours from now, in those four hours simple things you can do are analgesia and IV fluid resuscitation,’ he said.
 
‘Those are the important things that must be initiated so that the patient doesn’t lose those valuable four hours while waiting for a transfer or in the process of being transferred to a tertiary care centre.’
 
While gallstones and alcohol use are the most common causes of acute pancreatitis, accounting for 60–75% of cases, Dr Barreto says it is not always one factor alone that causes an episode.
 
Rather, the research authors highlight the possibility of more than one risk factor working in tandem.
 
‘Some patients say “I’ve just had a glass of wine, why did I develop it? I’m not a person who drinks a bottle of alcohol”,’ Dr Barreto said.
 
‘It’s a small amount of alcohol coupled with some sludge in the gallbladder, which may trigger off an episode of acute pancreatitis.’
 
For patients who have had a previous episode of acute pancreatitis and their history is known, Dr Barreto says GPs are paramount in continuing to educate patients around risks and prevention.
 
‘I work in a tertiary centre and we give patients as much information as possible. But sometimes, let’s be honest, we may miss out something, or sometimes the patient is so inundated with the whole episode of being in hospital that they may forget,’ he said.
 
‘So the GP serves as one of the biggest pivots around which our medical health system revolves, by reinforcing, reminding and empowering patients.’
 
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