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Clinical Review State of the Art Review

Management of severe acute pancreatitis

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6227 (Published 02 December 2019) Cite this as: BMJ 2019;367:l6227

Rapid Response:

Re: Management of severe acute pancreatitis

Dear Editor,

Thank-you for an interesting review on the topic. There is one area that is not mentioned of interest to the reader.

Colonic complications appear to be an all too common occurrence in acute necrotising pancreatitis and may pay an important influence in the final pathway to death. Colonic perforation is cited as a rare complication of acute pancreatitis. This follows a single study of 100 patients with acute pancreatitis in 1967(1). Data from a number of sources suggests that colonic complications are in fact common in patients with necrotising pancreatitis(2). This is a difficult diagnosis to make clinically and is often only made incidentally on CT or at laparotomy. The bottom line here is that the interaction between the colon and necrotic material is complex, and of vital importance to a patient’s outcomes. Through a combination of local vascular dysfunction, from the SIRS response and direct inflammation from necrotic material the microvasculature of the large bowel is particularly compromised. This may result in a number of sequela including colonic necrosis, perforation, bleeding, delayed colonic stenosis and strictures, and increased translocation of bacteria leading to subsequent infected necrosis (1,2,3,4,5). This usually occurs as late complications and is associated with severe disease.

The best available data suggests that these are common complications from necrotising pancreatitis occurring in 15% of patients with severe disease but could be as high as 40% in patients with necrotising pancreatitis(2). This topic requires further investigation and research to establish both the current frequency of complications and methods of reducing or attenuating harm from the complications. In the meantime, clinicians should remain vigilant to the possibility of these colonic complications. Further research may be warranted to examine the potential for interventions to reduce the microvascular changes leading to necrosis (such as early minimally invasive necrosectomy(5) and antioxidants).

Aside from this minor addition, thank-you for a providing an excellent article on the current state of play in research and care of patients suffering from this most terrible disease.

Kind regards,

References:
1) Lukash WM. Complications of acute pancreatitis. Unusual sequelae in 100 cases. Arch Surg 1967; 94: 848-52.
2) Mohamed S & Siriwardena A. Understanding the colonic complications of pancreatitis. Pancreatology. 2008;8:153–158.
3) Van Minnen et al. Colonic involvement in acute pancreatitis. A retrospective study of 16 patients. Dig Surg. 2004;21(1):33-38.
4) Aldridge MC, Francis ND, Glazer G, Dudley HAF: Colonic complications of severe acute pancreatitis. Br J Surg 1989;76:362–367.
5) Puri Y et al, Successful Management of Gastrointestinal Haemorrhage Associated with Ischaemic Colonic Ulceration in Acute Pancreatitis with Video Assisted Retroperitoneal Debridement. JOP. J Pancreas (Online) 2011 May 6; 12(3):271-273.Hospital, Paris, France

Competing interests: No competing interests

10 December 2019
Sam Rowe
Registrar in GIM/ICU
Devon, UK