Original Contribution | Published:

Pancreas and Biliary Tract

Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis

The American Journal of Gastroenterology volume 112, pages 797803 (2017) | Download Citation

Abstract

Objectives:

Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis.

Methods:

Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer’s solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0–10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet.

Results:

The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21–4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02–0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01–0.49). No patients developed signs of volume overload.

Conclusions:

Early aggressive intravenous hydration with Lactated Ringer’s solution hastens clinical improvement in patients with mild acute pancreatitis.

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References

  1. 1.

    , , et al. Burden of gastrointestinal, liver, and pancreatic diseases in the United States. Gastroenterology 2015;149:1731–1741 e3.

  2. 2.

    , , et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400–1415 1416.

  3. 3.

    , , et al. Fluid resuscitation in acute pancreatitis. Clin Gastroenterol Hepatol 2008;6:1070–1076.

  4. 4.

    , , et al. Prognostic factors in acute pancreatitis. Gut 1984;25:1340–1346.

  5. 5.

    , , et al. Simple scoring system for the prediction of the prognosis of severe acute pancreatitis. Surgery 2007;141:51–58.

  6. 6.

    , , et al. Elevated serum creatinine as a marker of pancreatic necrosis in acute pancreatitis. Am J Gastroenterol 2009;104:164–170.

  7. 7.

    , , et al. Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 2009;137:129–135.

  8. 8.

    , , et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol 2011;9:1098–1103.

  9. 9.

    , , et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139:69–81.

  10. 10.

    , , . Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas 2000;20:367–372.

  11. 11.

    , , et al. Hemoconcentration and pancreatic necrosis: further defining the relationship. Pancreas 2006;33:169–173.

  12. 12.

    , , et al. Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol 2001;96:2081–2085.

  13. 13.

    , , et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011;9:705–709.

  14. 14.

    , , et al. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study. Am J Gastroenterol 2011;106:1843–1850.

  15. 15.

    , , et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009;9:770–776.

  16. 16.

    , , et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011;9:710–717 e1.

  17. 17.

    , , et al. Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J (Engl) 2009;122:169–173.

  18. 18.

    , , et al. Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J (Engl) 2010;123:1639–1644.

  19. 19.

    , , et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–111.

  20. 20.

    , , et al. Clinical trial: oral feeding with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis. Aliment Pharmacol Ther 2008;28:777–781.

  21. 21.

    , , et al. Microcirculatory changes in sodium taurocholate-induced pancreatitis in rats. Am J Physiol 1991;260:G346–G351.

  22. 22.

    , , et al. Splanchnic and pancreatic tissue perfusion in experimental acute pancreatitis. Scand J Gastroenterol 2002;37:845–849.

  23. 23.

    , , et al. Splanchnic tissue perfusion in acute experimental pancreatitis. Scand J Gastroenterol 1999;34:308–314.

  24. 24.

    , , et al. Therapeutic regimens in acute experimental hemorrhagic pancreatitis. Effects of hydration, oxygenation, peritoneal lavage, and a potent protease inhibitor. Gastroenterology 1988;95:1648–1657.

  25. 25.

    , , et al. Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better? Clin Nutr 2006;25:497–504.

  26. 26.

    , , et al. Blood urea nitrogen in the early assessment of acute pancreatitis: an international validation study. Arch Intern Med 2011;171:669–676.

  27. 27.

    , , et al. Update of the Atlanta Classification of severity of acute pancreatitis: should a moderate category be included? Pancreatology 2010;10:613–619.

  28. 28.

    , , et al. Acute Pancreatitis Clinical Activity Index (AP-CAI) at discharge predicts readmission for acute pancreatitis. Am J Gastroenterol 2016;111:S1.

  29. 29.

    , , . Can the time course of systemic inflammatory response syndrome score predict future organ failure in acute pancreatitis? Pancreas 2014;43:1101–1105.

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Author information

Affiliations

  1. Division of Gastroenterology, University of Southern California, Keck School of Medicine, Los Angeles, California, USA

    • James L Buxbaum
    • , Michael Quezada
    • , Ben Da
    • , Niraj Jani
    • , Didi Mwengela
    •  & Thomas Kelly
  2. Department of Preventive Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, USA

    • Christianne Lane
  3. Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, USA

    • Paul Jhun
  4. Department of Emergency Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, USA

    • Kiran Dhanireddy
  5. Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA

    • Loren Laine
  6. VA Connecticut Healthcare System, West Haven, Connecticut, USA

    • Loren Laine

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Competing interests

Guarantor of the article: James Buxbaum, MD.

Specific author contributions: Concept and design: J.B., T.K., C.L., P.J. and K.D.; acquisition of data: J.B., M.Q., B.D., N.J., D.W., T.K., P.J. and K.D.; statistical analysis and interpretation of data: J.B., B.D., M.Q., C.L. and L.L.; drafting and revision of manuscript: J.B., M.Q., B.D., N.J., C.L., D.M., T.K., P.J., K.D. and L.L.

Financial support: This publication was supported by NIH/NCRR SC CTSI Grant Number UL1TR000130. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Potential competing interests: None.

Corresponding author

Correspondence to James L Buxbaum.

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DOI

https://doi.org/10.1038/ajg.2017.40

SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg

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