Pharmacopoeia of acute pancreatitis: Is the roster complete?

Abstract

Acute pancreatitis is one of the most common diseases in the everyday’s practise of gastroenterologists and surgeons. However, the physicians’ therapeutic armamentarium is very limited. The present letter to the editor briefly describes the recent evidence from the literature with the aim to optimize a conservative management of patients with acute pancreatitis.

Key Words: Acute pancreatitis; Conservative treatment; Enteral nutrition

TO THE EDITOR

In a recent issue of the Journal, I read with interest the article by Bang and co-authors[1], who reviewed the current possibilities of pharmacological prevention and treatment of patients with acute pancreatitis. Obviously, the chosen topic is of contemporary interest from both scientific and practical points of view, as the therapeutic armamentarium for this disease is fairly scarce. Herewith, I would like to make a brief comment on the list of options considered in the referred review.

A substantial part of the article by Bang et al[1] is devoted to the pharmacological prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis. Unfortunately, the promising potential of many drugs in the experimental studies has never been confirmed in the clinical trials and the data from many reports are inconsistent. At the same time, as a recent meta-analysis of randomised controlled trials[2] revealed no difference in outcomes between patients with acute pancreatitis but without coexisting acute cholangitis who received either early ERCP or conservative care, I would argue that the best preventive strategy for post-ERCP acute pancreatitis is to obviate the unnecessary ERCP, i.e. to use it only as a therapeutic but not as a diagnostic modality. Thus, it should be mainly reserved for patients with acute cholangitis, the incidence of which is marginal. In contrast, the majority of patients without cholangitis should be diagnosed noninvasively by endoscopic ultrasonography or by magnetic resonance tomography, which are virtually riskless. Adherence to this strategy may drastically diminish the need for pharmacological prevention of post-ERCP acute pancreatitis.

Another matter of concern is that Bang et al[1] did not consider a favorable effect of enteral nutrition in patients with (severe) acute pancreatitis. Probably, this is because enteral nutrition has been viewed as a supportive care for years. Indeed, in the majority of clinical settings, it should be considered so, because it is possible to demonstrate a beneficial effect of enteral nutrition only on nutritional parameters (body weight, nitrogen balance etc), which are essentially surrogate endpoints. However, the use of enteral nutrition in acute pancreatitis, unlike many other pathologies, is associated with a significant reduction in the incidence of clinically meaningful outcomes (infectious complications, need for surgery, mortality) coherently derived from nearly a dozen of randomized controlled trials. The findings from only high quality of these studies have been statistically aggregated in a recent meta-analysis[3], showing a significantly reduced risk of total infectious complications [relative risk (RR) = 0.47, 95% confidence interval (CI) = 0.28-0.77, P < 0.001], pancreatic infectious complications (RR = 0.48, 95% CI = 0.26-0.91; P = 0.02), need for surgery (RR = 0.37, 95% CI = 0.21-0.65, P = 0.001), and mortality (RR = 0.32, 95% CI = 0.11-0.98, P = 0.03) with the use of enteral nutrition in patients with severe acute pancreatitis.

Furthermore, as Dorland’s medical dictionary[4] defines a drug as “any chemical compound that may be used in or administered to humans or animals as an aid in the diagnosis, treatment, or prevention of diseases or other abnormal conditions, for the relief of pain or suffering, or to control or improve any physiologic or pathologic condition”, it seems to me that it is time now to consider enteral nutrition as a full-fledged drug in patients with acute pancreatitis.