Managing Patients With Acute Pancreatitis
What is the current role of somatostatin in the treatment of acute pancreatitis? What is the standard accepted line of treatment for acute pancreatitis?

Somatostatin and its long-acting analogue, octreotide, are potent inhibitors of exocrine secretion of the pancreas, which plays an important role in the pathogenesis of acute pancreatitis. In addition, somatostatin and octreotide have direct anti-inflammatory and cytoprotective effects. It has therefore been suggested that somatostatin and octreotide be used in the treatment and prevention of acute pancreatitis, and this concept has been studied extensively over the past 2 decades. The results of these trials have been mixed. While some initial smaller-scale studies showed moderate benefits, a recent multicenter randomized study involving over 300 patients revealed no benefit of octreotide with regard to outcome or progression of pancreatitis. Although somatostatin does appear to have a modest effect on preventing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients, it is generally agreed that the treatment of all patients undergoing ERCP with prophylactic somatostatin is probably not cost-effective. In summary, there is currently no widely accepted role for these agents in the treatment of acute pancreatitis.

Dorta and others have suggested an indication for somatostatin and octreotide in the treatment of pancreatic fistulae. The idea here is that the antisecretory effect of these agents may promote healing of fistulae. To date, only case reports and small case series have been published in support of this concept. While confirmation of efficacy in larger-scale studies is lacking, this represents a simple intervention for a difficult-to-manage clinical problem, and therefore, in conjunction with other therapies, such as pancreatic stenting, may be tried in an attempt to avoid surgical intervention.

The main therapeutic principles for managing patients with acute pancreatitis have not changed in recent years. Treatment relies on supportive care with close attention to volume status and electrolyte balance, fasting of the patient, and pain management using narcotic agents. Predicting the severity of an attack (by computed tomography scanning, the use of any of the established scoring systems [eg, Ranson's criteria], or detailed clinical assessment) allows triaging of patients to intensive care units or a regular floor. Patients with predicted severe pancreatitis will benefit from close monitoring for early detection of complications, including organ failure, pancreatic necrosis with or without infection, pseudocyst formation, etc. Recent controlled trials have clarified the role of prophylactic broad-spectrum antibiotics and these are now widely recommended for patients with predicted severe pancreatitis to prevent infected pancreatic necrosis. Adequate nutritional support is required for patients with severe pancreatitis and those with a protracted course of the disease. While enteral nutrition appears to be superior to parenteral nutrition, the decision between placement of a nasojejunal feeding tube and the use of total parenteral nutrition needs to be individualized, because the former may not be tolerated by all patients due to coexistent small bowel ileus.