Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?

Abstract

AIM: To systematically review evidence on pathop-hysiology of intra-abdominal pressure (IAP) in acute pancreatitis (AP) with its clinical correlates. METHODS: Systematic review of available evidence in English literature with relevant medical subject heading terms on PubMed, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved. RESULTS: Intra-abdominal hypertension (IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital (prevalence increasing to 50% in those with severe disease). Abdominal compart-ment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-Biliary-Pancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums (such as fluid therapy, nutrition and antibiotic prophy-laxis) with potential to further individualize treatment in AP. CONCLUSION: We suggest that IAP be given its due place in future practice guidelines and that recom-mendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH. Core tip: Intra-abdominal hypertension is not merely an epiphenomenon but offers a unique point of specific intervention in acute pancreatitis and there is increa-sing data to show improved mortality with appropriate management. It is frequent and may be observed in at least 50% patients with severe disease. Moreover it acts as confounder in management related issues of fluid therapy, nutritional support and antibiotic prophylaxis; and understanding its pathophysiology coherently explains many dichotomies which presently lowers internal validity of much available evidence. Incorporating surveillance for intra-abdominal pressure in select subgroup of patients may help better tailor individualized treatment to patients with most severe spectrum of disease. Recommendations by World Society of the Abdominal Compartment Syndrome may be followed by practicing clinician to guide decision making.