What are the guidelines for a patient with necrotizing pancreatitis and splenic thrombosis?

Management Guidelines for Necrotizing Pancreatitis with Splenic Thrombosis

Patients with necrotizing pancreatitis and splenic thrombosis require management in a high dependency unit or intensive care unit with full monitoring and systems support to reduce morbidity and mortality. 1

Initial Management

• All patients with severe acute pancreatitis (including necrotizing pancreatitis) should be managed in an HDU or ICU setting with full monitoring and systems support 1
• Monitoring should include regular hourly assessment of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1
• Fluid resuscitation should be carefully managed with moderate rather than aggressive approach to prevent fluid overload 2
• Pain management should follow a multimodal approach, with dilaudid preferred over morphine or fentanyl in non-intubated patients 1
• Epidural analgesia may be considered for patients with severe acute pancreatitis requiring high doses of opioids for extended periods 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1
• Enteral feeding should be initiated early (within 24-72 hours) via nasogastric or nasojejunal tube 1
• Both gastric and jejunal feeding can be delivered safely 1
• In patients with splenic vein thrombosis and intra-abdominal pressure (IAP) < 15 mmHg, early enteral nutrition should be initiated via nasojejunal (preferred) or nasogastric tube 1
• For patients with IAP > 15 mmHg, enteral nutrition should be initiated via nasojejunal route starting at 20 mL/h, increasing according to tolerance 1
• If enteral nutrition is not tolerated, partial parenteral nutrition should be considered to reach caloric and protein requirements 1

Antibiotic Management

• Prophylactic antibiotics for prevention of pancreatic necrosis infection are not routinely recommended 1, 3
• Antibiotics should be administered when specific infections occur (chest, urine, bile, or cannula related) 1
• For confirmed infected necrosis or strong suspicion of infection (gas in collection, bacteremia, sepsis, clinical deterioration), broad-spectrum antibiotics with ability to penetrate pancreatic necrosis should be used 3
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 1

Management of Pancreatic Necrosis

• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast 1
• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 1
• Pancreatic debridement should be avoided in the early, acute period (first 2 weeks) as it increases morbidity and mortality 3
• Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication 3, 4
• A step-up approach is recommended: initial percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic necrosectomy if needed, and then surgical debridement as a last resort 3, 4

Management of Splenic Vein Thrombosis

• For patients with necrotizing pancreatitis and splenic vein thrombosis, anticoagulation therapy should be considered to prevent progression of thrombosis and potential complications 5
• Regular monitoring of the thrombosis through imaging is essential to assess progression or resolution 5
• Patients with splenic vein thrombosis should be monitored for signs of gastric varices or splenomegaly, which may develop as complications 5

Interventional Approaches

• Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line approaches for managing walled-off pancreatic necrosis (WON) 3
• Endoscopic therapy through transmural drainage may be preferred as it avoids the risk of forming a pancreatocutaneous fistula 3
• Self-expanding metal stents in the form of lumen-apposing metal stents are superior to plastic stents for endoscopic transmural drainage of necrosis 3, 5
• Minimally invasive surgical techniques (videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement) are preferred to open surgical necrosectomy when possible 3, 4

Special Considerations for Biliary Pancreatitis

• Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who have cholangitis, jaundice, or a dilated common bile duct 1
• The procedure is best carried out within the first 72 hours after the onset of pain 1
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks 1

Referral Considerations

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications who may require intensive therapy unit care, or interventional radiological, endoscopic, or surgical procedures 1
• In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center 3