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Evidence for Acute Pancreatitis Therapy

Clinician's Brief (Capsule)

Internal Medicine

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November 2015

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This paper reviewed 158 articles relating to treatment recommendations for acute pancreatitis (AP) in both dogs and humans. It assigned each recommendation a level of evidence (LOE) explaining how well the treatment is supported by science or expert opinion. Level A represented recommendations with the highest LOE and Level D the lowest. Treating existing dehydration and ongoing fluid losses with IV fluid therapy—typically a mainstay of AP treatment—carries a reasonable LOE. Antiemetics help decrease risk for dehydration and improve overall comfort level; use of maropitant as a central and peripheral antiemetic is the preferred first-line treatment. Analgesia to control both local and visceral pain can be achieved via single-agent or multimodal therapy using opioids, NMDA antagonists, α2-adrenergic agonists, and adjuvant drugs (eg, tramadol, gabapentin). Lidocaine is an attractive option for pain control in AP because of its anti-inflammatory properties and ability to control central and peripheral pain when administered as a CRI. 

Nutritional management in AP is another area gaining attention. The prior recommendation of “resting the pancreas” and keeping the patient NPO has given way to a new theory that feeding the patient as soon as it is tolerated helps deliver nutrition directly to damaged intestinal cells while reducing bacterial translocation and decreasing pancreatic inflammation. Many treatment recommendations are extrapolated from human patients with AP; larger veterinary studies are required to fully evaluate ideal treatment for AP in dogs.

Global Commentary

The practice of withholding food from dogs with AP probably stems from Pavlov’s classic experiments on gastric acid secretion. Pavlov (with Heidenhain) showed that the anticipation of food, as well as its ingestion and digestion, caused acid stimulation and pancreatic-enzyme secretion through various neurohormonal pathways.1 Therefore, logically, withholding food and even not exposing the dog to the sight or smell of food should reduce the pancreatic-enzyme secretion that causes pancreatitis. 

The evidence now is that “resting the pancreas” is actually harmful and the prognosis is improved if some enteral nutrition is provided in the first 48 hours. However, enteral nutrition has only become possible because of the development of effective antiemetics and improved analgesia.—Ed Hall, MA, VetMB, PhD, DECVIM-CA

References

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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