Pancreatic head mass: how can we treat it? Acute pancreatitis: conservative treatment.

Acute pancreatitis (AP) is an inflammatory disease of the pancreas that often carries a complicated and severely life-threatening course and still remains a demanding and dreadful disease for both patients and clinicians. Over the last few years, changes in the understanding of the patho-physiologic factors, combined with recent technologic advances, have fortunately led to improvements in the management of these patients. From the practical standpoint, some important indications should be pursued to optimize the treatment: a) an early objective severity assessment by simple means is mandatory, and all patients should be considered as suffering from severe AP until proven otherwise; in this respect, the recent clinically based classification system for AP the Atlanta classification [1] seems to be a valid method of discriminating between the mild and severe forms; b) the treatment should be started as early as possible and should be primarily addressed to the removal of etiological factor(s) and to support the hydroelectrolytic, caloric and circulatory balance; specific treatment (antiproteases, antibiotics) should be added in severe cases; the main goals of medical therapy also include the need of limiting systemic complications and prevention of pancreatic infection once necrosis takes place; c) referral to a specialized Center should be carefully considered for those patients with severe disease at major risk of lifethreatening complications; as suggested by the UK guidelines [2], a specialized Center for the management of severe AP should be characterised by the presence of the following: • a large general hospital with a full range of principal medical and surgical specialities; • a multidisciplinary team of specialists in internal medicine, surgery, endoscopy, intensive care, pathology with a full staff of support; • a contrast-enhanced-tomography-scan (CECT-scan) and ultrasonography (US) with full-time availability together with physicians expert in percutaneous procedures; the addition of magnetic resonance imaging and angiographic facilities would be helpful but not essential; • experencied endoscopists with endoscopic retrograde cholangiopancreatography (ERCP) and related interventional procedures available daily; d) the approach to managing AP should be interdisciplinary to get the best treatment results for these patients.