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      Pharmacological Prevention and Treatment of Acute Pancreatitis: Where Are We Now?

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          Abstract

          Acute pancreatitis is a disease of increasing prevalence, unchanged mortality over many decades, and limited treatment strategies. Progress has been made in developing therapies that reduce the rate of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatitis and in preventing infected pancreatic necrosis with intravenous carbapenems. Attempts at reducing pancreatic enzyme output or inhibiting the activity of digestive enzyme proteases have not yielded encouraging results – nor have anti-inflammatory strategies for the treatment of acute pancreatitis been found to be effective so far. Future therapeutic options that are presently being developed or under investigation attempt to restore pancreatic secretory function, interfere with inflammatory pathways in a more effective manner, or inhibit digestive enzyme proteases more selectively.

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          Most cited references43

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          Diclofenac reduces the incidence of acute pancreatitis after endoscopic retrograde cholangiopancreatography.

          Acute pancreatitis following endoscopic retrograde cholangiopancreatography presents a unique opportunity for prophylaxis and early modification of the disease process because the initial triggering event is temporally well defined and takes place in the hospital. We report a prospective, single-center, randomized, double-blind controlled trial to determine if rectal diclofenac reduces the incidence of pancreatitis following cholangiopancreatography. Entry to the trial was restricted to patients who underwent endoscopic retrograde pancreatography or had manometrically verified sphincter of Oddi hypertension. Immediately after endoscopy, patients were given a suppository containing either 100 mg diclofenac or placebo. Estimation of serum amylase levels and clinical evaluation were performed in all patients. A total of 220 patients entered the trial, and 110 received rectal diclofenac. Twenty-four patients developed pancreatitis (11%), of whom 7 received rectal diclofenac and 17 received placebo (P < 0.05). This trial shows that rectal diclofenac given immediately after endoscopic retrograde cholangiopancreatography can reduce the incidence of acute pancreatitis.
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            High early mortality rate from acute pancreatitis in Scotland, 1984-1995.

            Death from acute pancreatitis within the first week after admission is usually a consequence of multiple organ dysfunction. Reports from specialist centres suggest that, with improvements in resuscitation and supportive care, such deaths are becoming uncommon but it is unclear if this is reflected in a decrease in early mortality rate from acute pancreatitis in the general population. Data concerning patients discharged with a diagnosis of acute pancreatitis (International Classification of Disease-9 code 577.0) between 1984 and 1995 were obtained from the Information and Statistics Division, National Health Service in Scotland, and analysed on a computer database. The incidence of acute pancreatitis in Scotland continues to increase in both sexes. The in-hospital mortality rate (death from all causes) was 7.5 per cent and showed a slight but significant downward trend over the period of study. Death within 7 days of hospital admission accounted for 53.7 per cent of all deaths and the proportion of early deaths did not decline over the study interval. These results suggest that scope remains for considerable improvement in the early management of acute pancreatitis. There is an urgent need to improve the early recognition of severe pancreatitis coupled to a willingness on behalf of clinicians to transfer these patients at an early stage to a centre with high-dependency and intensive care facilities supervised by a multidisciplinary team with expertise in the endoscopic, radiological and surgical management of these patients.
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              Hospital admission for acute pancreatitis in an English population, 1963-98: database study of incidence and mortality.

              To investigate trends in the incidence of acute pancreatitis resulting in admission to hospital, and mortality after admission, from 1963 to 1998. Analysis of hospital inpatient statistics for acute pancreatitis, linked to data from death certificates. Southern England. 5312 people admitted to hospital with acute pancreatitis. Incidence rates for admission to hospital, case fatality rates at 0-29 and 30-364 days after admission, and standardised mortality ratios at monthly intervals up to one year after admission. The incidence of acute pancreatitis with admission to hospital increased from 1963-98: age standardised incidence rates were 4.9 per 100,000 population in 1963-74, 7.7 in 1975-86, and 9.8 in 1987-98. Age standardised case fatality rates within 30 days of admission were 14.2% in 1963-74, 7.6% in 1975-86, and 6.7% in 1987-98. From 1975-98, standardised mortality ratios at 30 days were 30 in men and 31 in women (compared with the general population of equivalent age in the same period = 1), and they remained significantly increased until month 5 for men and month 6 for women. Incidence rates for acute pancreatitis with admission to hospital rose in both men and women from 1963 to 1998, particularly among younger age groups. This probably reflects, at least in part, an increase in alcoholic pancreatitis. Mortality after admission has not declined since the 1970s. This presumably reflects the fact that no major innovations in the treatment of acute pancreatitis have been introduced. Pancreatitis remains a disease with a poor prognosis during the acute phase.
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                Author and article information

                Journal
                DDI
                Dig Dis
                10.1159/issn.0257-2753
                Digestive Diseases
                S. Karger AG
                978-3-8055-8128-8
                978-3-318-01356-6
                0257-2753
                1421-9875
                2006
                May 2006
                12 May 2006
                : 24
                : 1-2
                : 148-159
                Affiliations
                aClinic for General Internal Medicine, Centre of Medicine, Municipal Clinic of Lüneburg, Lüneburg, and bDepartment of Gastroenterology, Endocrinology, and Nutrition, Ernst-Moritz-Arndt University of Greifswald, Greifswald, Germany
                Article
                90318 Dig Dis 2006;24:148–159
                10.1159/000090318
                16699273
                a6307b04-78b2-49fe-992d-26e4f7aeeb78
                © 2006 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Page count
                Tables: 6, References: 157, Pages: 12
                Categories
                Review Article

                Oncology & Radiotherapy,Gastroenterology & Hepatology,Surgery,Nutrition & Dietetics,Internal medicine
                Post-endoscopic retrograde cholangiopancreatography pancreatitis,Pharmacological treatment,Acute pancreatitis,Pharmacological prevention

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