tailieunhanh - Emergencies and Complications in Gastroenterology - part 5

Mặc dù bằng chứng không phải là kết luận để hỗ trợ dinh dưỡng đường ruột ở tất cả các bệnh nhân viêm tụy cấp nặng, các tuyến đường đường ruột có thể được sử dụng nếu có thể được dung thứ. | 39 40 others did not show any beneficial effects 41 . Although the evidence is not conclusive to support enteral nutrition in all patients with severe acute pancreatitis the enteral route may be used if that can be tolerated. The supportive therapy also includes an adequate analgesia 34 35 . Several treatment regimens including opioids procaine infusion epidural blockade have been widely advocated. However these strategies of pain management are rather based on empirical experience than on results of controlled prospective trials 42 . In addition to the sole supportive care the principles of intensive care therapy in severe pancreatitis include elimination of the cause of the primary insult whenever possible. A causative therapy exists for severe gallstone pancreatitis with an impacted stone biliary sepsis or obstructive jaundice 43-45 . Endoscopic retrograde cholangiopancreatography ERCP and endoscopic sphincterotomy ameliorate symptoms and progression of the disease when applied early 46 . Secondary causes of organ failure such as hypovolemia tissue hypoperfusion and hypoxemia must also be identified and treated promptly. There is some evidence that vigorous fluid resuscitation may be associated with resolution of organ failure 47 . As plasma expanders are more effective and long-acting colloids should be preferred compared to crystalloids 35 36 . Dextran 60 seems to be the most potent colloid available for treatment of acute pancreatitis as it is characterized not only by a long intravascular persistence but also by antithrombotic properties and inhibitory effects on leukocyte adhesion 48 49 . Moreover a clinical trial indicated that dextran can be applied safely in acute pancreatitis 50 . Multiple mediators of the inflammatory cascade including oxygen free radicals vasoactive mediators cytokines as well as leukocyte and endothelial activation and pancreatic ischemia have been identified as important steps in the pathogenesis of acute necrotizing pancreatitis .