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CHAPTER 108: Acute Pancreatitis 1031

United States. These pharmacologic agents should be continued for 3 to • Gustot T, Durand F, Lebrec D, et al. Severe sepsis in cirrhosis.
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5 days, during which the risk of rebleeding is at its peak. Hepatology. 2009;50(6):2022-2033.
While pharmacologic therapy should be initiated once the diagnosis
of acute variceal bleed is suspected, EGD with possible endoscopic ther- • Han MK, Hyzy R. Advances in critical care management of
apy should be performed within 12 hours of admission. Endoscopic hepatic failure and insufficiency. Crit Care Med. 2006;34(suppl 9):
37
variceal ligation (EVL) has been shown to be superior to sclerotherapy S225-S231.
in the acute control of esophageal variceal bleeding. However, if EVL • Krowka MJ, Plevak DJ, Findlay JY, et al. Pulmonary hemody-
is not technically feasible, sclerotherapy may be attempted. In those namics and perioperative cardiopulmonary-related mortality in
37
patients where control of esophageal variceal bleeding is not feasible patients with portopulmonary hypertension undergoing liver
with combined pharmacologic and endoscopic therapy, or if recurrence transplantation. Liver Transpl. 2000;6(4):443-450.
occurs early, then TIPS may provide improved survival. TIPS is gener- • Murray KF, Carithers RL Jr. AASLD practice guidelines: eval-
ally considered first-line treatment for uncontrolled gastric variceal uation of the patient for liver transplantation. Hepatology.
bleeding after a failed endoscopic attempt. Finally, balloon tamponade 2005;41(6):1407-1432.
35
such as with a Sengstaken Blakemore tube or Minnesota tube is effective
in temporary control of variceal bleeding. Balloon tamponade should • Salerno F, Gerbes A, Gines P, et al. Diagnosis, prevention and
be restricted to patients with variceal hemorrhage refractory to medi- treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56(9):
cal or endoscopic management who are awaiting a more definitive 1310-1318.
treatment such as emergent TIPS. Balloon tamponade is associated • Sharma P, Rakela J. Management of pre-liver transplantation
with lethal complications including aspiration, esophageal perforation/ patient—part 2. Liver Transpl. 2005;11(3):249-260.
necrosis, and migration. Airway protection is mandatory with the use
of this device. 35
REFERENCES
LIVER TRANSPLANTATION Complete references available online at www.mhprofessional.com/hall
Liver transplantation has offered patients with acute or chronic liver
disease improved survival and quality of life. The limited availabil-
ity of organs prompted use of objective medical criteria reflecting CHAPTER Acute Pancreatitis
severity of disease to facilitate appropriate allocation of organs for
patients in need of a liver transplantation. The implementation of the 108 Ajaypal Singh
Model for End Stage Liver Disease (MELD) allocation system in 2002, Andres Gelrud
while not without its flaws, allowed for a more objective prioritization
of deceased donor organs based on specific medical criteria. Using
41
the MELD model, patients are designated a number between 6 and
40 based on variables including INR, creatinine, bilirubin, and need KEY POINTS
for renal replacement therapy. Higher MELD scores correspond to
higher mortality rates. Patients with MELD scores of 15 or more have • Acute pancreatitis is a frequent cause of gastrointestinal-related
been shown to have improved mortality with liver transplantation. critical illness.
42
Patients with decompensated chronic liver disease being managed in • Most cases are caused by alcohol and gallstones; other etiologies
the intensive care unit often have a rise in their MELD score, indica- include hypertriglyceridemia, post-ERCP pancreatitis, hypercalce-
tive of their acute illness and worsening hepatic failure. Evaluation mia, trauma, infections, and medications.
of the patient’s clinical stability, transplant candidacy, and need for • Two of the following three criteria establish the diagnosis of
urgent liver transplantation in the setting of critical illness involves acute pancreatitis: sudden onset of characteristic abdominal pain;
the collaborative efforts of the intensivist, transplant hepatologist, and serum amylase and/or lipase above three times normal; pancreatic
transplant surgeon. inflammation on imaging studies.
• There are two types of acute pancreatitis—interstitial edematous
SUMMARY and necrotizing. The former has pancreatic enlargement with
diffuse pancreatic and peripancreatic inflammation. The latter
The intensive care management of cirrhotic patients requires a detailed has necrosis of pancreatic and/or peripancreatic tissue, in addi-
multiorgan system-based approach to critical illness. The distinct tion to inflammatory changes.
pathophysiology of acute on chronic liver failure requires specific • Early crystalloid administration in fluid-responsive patients is
management strategies to address hepatic and extrahepatic organ important in the management of acute pancreatitis.
dysfunction. A team-based approach to clinical decision making that
involves the transplant hepatologist and intensivist is essential for effec- • Early enteral nutrition has been validated as an important com-
tive critical care management of patients with liver failure. ponent of the management of acute pancreatitis; avoiding enteral
feeding and/or use of parenteral nutrition is not recommended.
• There is no role for prophylactic antibiotics in the management
of acute pancreatitis; however, broad spectrum antibiotics (eg,
KEY REFERENCES carbapenems) are indicated in the presence of documented or
suspected pancreatitic infection.
• Canabal JM, Kramer DJ. Management of sepsis in patients with
liver failure. Curr Opin Crit Care. 2008;14(2):189-197. • Endoscopic retrograde cholangiopancreatography (ERCP) is indi-
• Fernandez J, Escorsell A, Zabalza M, et al. Adrenal insuf- cated in patients with acute gallstone pancreatitis with cholangitis
and those with pancreatic duct disruption.
ficiency in patients with cirrhosis and septic shock: effect
of treatment with hydrocortisone on survival. Hepatology. • Endoscopic debridement is superior to open necrosectomy for the
2006;44(5):1288-1295. management of mature, walled-off fluid collections.

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