What is the treatment for pancreatitis?

From the Guidelines

The treatment of pancreatitis should focus on supportive care, including early oral feeding, enteral nutrition, and aggressive fluid resuscitation, as these approaches have been shown to improve outcomes and reduce morbidity and mortality 1.

Overview of Pancreatitis Treatment

The management of pancreatitis involves a multifaceted approach that prioritizes supportive care to allow the pancreas to heal. This includes:

• Aggressive fluid resuscitation to prevent dehydration and support organ function
• Pain management with medications such as morphine or hydromorphone
• Nutritional support, preferably through enteral nutrition, to reduce the risk of complications and promote healing
• Monitoring for and management of potential complications, such as infected necrosis, which may require antibiotics and drainage procedures

Key Recommendations

Based on the most recent and highest quality evidence:

• Early oral feeding is recommended within 24 hours as tolerated, rather than keeping the patient nil per os 1.
• Enteral nutrition is preferred over parenteral nutrition for patients with acute pancreatitis who are unable to feed orally 1.
• Prophylactic antibiotics are not recommended for all patients with acute pancreatitis, but should be used to treat infected severe acute pancreatitis 1.
• Cholecystectomy is recommended during the initial admission for patients with acute biliary pancreatitis 1.

Considerations for Severe Acute Pancreatitis

For patients with severe acute pancreatitis, more intensive care is necessary, including:

• Aggressive fluid resuscitation (5-10 mL/kg/hr initially)
• Close monitoring for complications, such as organ failure and necrosis
• Consideration of enteral nutrition via nasogastric (NG) or nasojejunal (NJ) routes if oral feeding is not tolerated 1

Lifestyle Modifications and Underlying Cause Management

Addressing underlying causes, such as removing gallstones in biliary pancreatitis or treating hypertriglyceridemia, and implementing lifestyle modifications, including alcohol cessation and a low-fat diet, are crucial components of pancreatitis management 1.

From the FDA Drug Label

INDICATIONS AND USAGE CREON is indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients. (1) The answer to the treatment of pancreatitis is not directly addressed in the provided drug label. Pancrelipase (PO) is indicated for the treatment of exocrine pancreatic insufficiency, but it does not directly state it is for the treatment of pancreatitis. 2

From the Research

Treatment Approaches for Pancreatitis

• The management of acute pancreatitis involves several key components, including fluid resuscitation, pain control, nutritional support, and antibiotic use 3.
• Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies, with lactated Ringer's solution being the preferred fluid type 4, 5.
• The use of lactated Ringer's solution has been shown to reduce systemic inflammation compared to normal saline in patients with acute pancreatitis 5.

Fluid Resuscitation

• The optimal timing, fluid type, volume, rate, and duration of fluid resuscitation in acute pancreatitis are still being debated, with some studies suggesting that early aggressive fluid resuscitation may not be beneficial for all patients 4.
• A study comparing lactated Ringer's solution to normal saline found that lactated Ringer's solution reduced systemic inflammation and C-reactive protein levels after 24 hours 5.
• However, another study found no significant difference in clinical outcomes between patients receiving lactated Ringer's solution and those receiving normal saline 6.

Other Management Strategies

• Antibiotics should only be administered when there is a proven or highly probable infection, rather than for prophylactic purposes 3, 7.
• Urgent endoscopic retrograde cholangiopancreatography (ERCP) is beneficial for patients with acute cholangitis, but not for those without cholangitis 3, 7.
• Same-admission cholecystectomy for mild biliary pancreatitis is safe and can prevent relapse, and is associated with lower costs compared to interval cholecystectomy 7.