From the Guidelines
The treatment of acute pancreatitis should focus on supportive care, including aggressive intravenous fluid resuscitation, pain control, and early enteral nutrition, as recommended by the most recent guidelines 1. The initial management of acute pancreatitis includes:
- Aggressive intravenous fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr for the first 24 hours, adjusting based on vital signs and urine output
- Pain control with opioid analgesics like morphine (2-4 mg IV every 4 hours) or hydromorphone (0.5-1 mg IV every 4 hours)
- Early enteral nutrition, preferably via oral route if tolerated, or nasojejunal feeding if necessary, as supported by the American Gastroenterological Association guidelines 1
- Monitoring for complications such as pancreatic necrosis, pseudocysts, or organ failure
- Addressing the underlying cause, such as gallstone removal or alcohol cessation, to prevent recurrence Antibiotics are not routinely recommended unless there is confirmed infection or necrotizing pancreatitis, as stated in the Italian Council for the Optimization of Antimicrobial Use guidelines 1. In severe cases, intensive care monitoring may be required, and ERCP may be needed within 24 hours for pancreatitis caused by gallstones with cholangitis or biliary obstruction, as recommended by the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1. The goal of treatment is to allow the pancreas to rest while maintaining nutritional status and preventing complications during the inflammatory process, ultimately reducing morbidity, mortality, and improving quality of life, as emphasized by the UK guidelines for the management of acute pancreatitis 1.
From the Research
Treatment of Acute Pancreatitis
- The treatment of acute pancreatitis involves aggressive fluid resuscitation, with the goal of reducing systemic inflammation and preventing complications 2.
- The choice of fluid for resuscitation is important, with lactated Ringer's solution being preferred over normal saline due to its ability to reduce systemic inflammation and improve outcomes 2, 3, 4.
- A systematic review and meta-analysis of randomized controlled trials found that fluid resuscitation with lactated Ringer's solution was associated with a significant reduction in the odds of intensive care unit admission and development of local complications compared to normal saline 3.
- Another systematic review and meta-analysis found that patients who received lactated Ringer's solution had significantly decreased odds of developing systemic inflammatory response syndrome (SIRS) at 24 hours, which is a marker of severe disease in acute pancreatitis patients 4.
Fluid Resuscitation Protocols
- Goal-directed fluid resuscitation protocols have been shown to be effective in reducing systemic inflammation and improving outcomes in patients with acute pancreatitis 2.
- However, the type of fluid used for resuscitation is also important, with lactated Ringer's solution being preferred over normal saline due to its anti-inflammatory effects 5, 4.
- A retrospective study found that the administration of lactated Ringer's solution in the first days of acute pancreatitis did not lead to improved clinical outcomes, but this study had limitations and the results should be interpreted with caution 5.
Clinical Outcomes
- The clinical outcomes of patients with acute pancreatitis can be improved with aggressive fluid resuscitation and the use of lactated Ringer's solution 2, 3, 4.
- A systematic review and meta-analysis found that mortality trended lower in the lactated Ringer's solution group, but this did not achieve statistical significance, and larger randomized controlled trials are needed to evaluate this association 4.
- The development of systemic inflammatory response syndrome (SIRS) at 24 hours is a marker of severe disease in acute pancreatitis patients, and lactated Ringer's solution has been shown to decrease the odds of developing SIRS at 24 hours 4.