Management of severe acute pancreatitis: an evolving approach.

No major breakthrough has occurred in our understanding of the etiology or pathogenesis of acute pancreatitis. However, significant advances in management of the disease have resulted in improved survival. These include disease severity assessment by Ranson's criteria or by similar other clinical methods, as well as by computerized tomography (CT). The use of contrast-enhanced CT has made possible early diagnosis of pancreatic necrosis by showing areas of hypoperfusion. Once the presence of necrosis is established, CT-guided needle aspiration of necrotic tissue can be performed for gram stain and for culture of bacteria. This approach makes possible earlier diagnosis of pancreatic sepsis, and hence earlier surgery. Other important contributions have been radiologic and endoscopic interventional techniques. Percutaneous catheter drainage of rapidly enlarging acute pseudocysts can obviate the serious complication of free rupture of pseudocysts into the peritoneal cavity; similar drainage of infected pseudocysts may also provide a definitive or at least a palliative therapy. Bleeding from eroded vessels, false aneurysms or pseudocysts can often be successfully controlled by selective angiography. In severe acute biliary pancreatitis, endoscopic sphincterotomy within 72 hours of admission has been shown to reduce morbidity, mortality, and hospital stay. These interventional techniques permit surgery to be postponed until the most optimal time. The advances cited above, as well as improved intensive care and nutritional management, are beginning to reduce the high mortality of severe acute pancreatitis.