On hospital day 3, abdominal pain continues for the 57-year-old man, made worse by oral intake. Abdominal US suggests next steps. What would you do?
Acute pancreatitis, CBD clear. The patient is admitted to your hospital with acute pancreatitis. Multiple gallstones are seen on abdominal ultrasound but the common bile duct is clear. He is started on IV Lactated Ringer’s solution, given pain medicine and kept NPO. On hospital day 3, pain continues to be significant, made worse with oral intake.
Pancreatic necrosis, SIRS-negative. Abdominal CT reveals necrosis of the pancreatic head and neck; although he is afebrile and SIRS-negative, pain continues to prohibit oral intake.
What is the next best step in management?
Answer: C. Place nasojejunal tube for post-pyloric feeding. Pancreatic necrosis is the result of severe acute pancreatitis secondary to gallstones. The necrosis is presumed sterile so IV antibiotics are not indicated; also, it is too early to consider endoscopic ultrasound guided therapy; TPN is typically not recommended.
Nasojejunal vs nasogastric feeding. Enteral feeding via nasojejunal tube will increase blood flow to the duodenum and pancreas to prevent further necrosis. An increasing body of evidence suggests that nasogastric feeding is noninferior to nasojejunal feeding in preventing pancreatic necrosis.
Follow Dr James on Twitter: @TedWJamesMD
Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association Institute Guideline on initial management of acute pancreatitis. Gastroenterol. 2018;154:1096-1101.