What is the treatment for acute pancreatitis in a patient with no history of alcohol (ethanol) use?

From the Guidelines

The treatment of acute pancreatitis in patients with no alcohol use should focus on goal-directed fluid resuscitation, early oral feeding, and enteral nutrition, as recommended by the American Gastroenterological Association institute guideline 1. The initial management of acute pancreatitis includes:

• Fluid resuscitation with lactated Ringer's solution or normal saline, with the goal of maintaining adequate urine output and blood pressure
• Pain control using opioid analgesics such as hydromorphone or morphine
• Early enteral nutrition within 24-48 hours if tolerated
• For patients with gallstone pancreatitis, early ERCP (within 24-48 hours) is recommended if there is evidence of cholangitis or biliary obstruction, followed by cholecystectomy during the same hospitalization or within 2-4 weeks after discharge
• Antibiotics are not routinely recommended unless there is evidence of infection or necrotizing pancreatitis A recent systematic review and meta-analysis compared aggressive and non-aggressive intravenous hydration for acute pancreatitis, and found that aggressive hydration may increase the risk of fluid overload and mortality in non-severe acute pancreatitis 1. However, the American Gastroenterological Association institute guideline 1 recommends goal-directed fluid resuscitation, which takes into account the individual patient's needs and response to treatment. Key considerations in the management of acute pancreatitis include:
• Close monitoring of vital signs, urine output, and laboratory values to assess for complications such as organ failure or pancreatic necrosis
• Addressing the underlying cause of pancreatitis, such as gallstones or other obstructive causes
• Providing supportive care, including pain management and nutritional support, to allow the pancreas to heal.

From the Research

Treatment of Acute Pancreatitis with No Alcohol Use

• The treatment of acute pancreatitis (AP) involves initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis 2.
• Recent updates suggest a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution, which has been shown to reduce systemic inflammation compared to saline in patients with AP 3, 4, 5.
• The use of lactated Ringer's solution has been associated with reduced hospital mortality rates and shorter ICU length of stay in critically-ill patients with AP 4.
• Early enteral feeding is also becoming a definitive part of AP treatment, and the routine use of prophylactic antibiotics is generally limited, with a procalcitonin-based algorithm being investigated to distinguish between inflammation and infection in patients with AP 2.
• For patients with local complications of AP, such as infected necrotizing pancreatitis, referral to specialist tertiary centers for further management, including drainage and/or necrosectomy, is recommended 2, 6.

Fluid Resuscitation

• Lactated Ringer's solution has been shown to have an anti-inflammatory effect in patients with AP, inhibiting the induction of inflammatory phenotype of macrophages and NF-κB activation 5.
• The use of lactated Ringer's solution has been compared to normal saline in several studies, with results suggesting that lactated Ringer's solution may have a survival benefit over normal saline in critically-ill patients with AP 4, 5.
• Goal-directed fluid resuscitation with lactated Ringer's solution has been shown to reduce systemic inflammation and improve outcomes in patients with AP 3, 5.

Nutritional Support and Antibiotic Use

• Early enteral feeding is recommended for patients with AP, as it has been shown to improve outcomes and reduce the risk of complications 2, 6.
• The use of antibiotics in AP is generally limited to patients with suspected or confirmed infection, and a procalcitonin-based algorithm may be used to guide antibiotic use 2.
• Patients with AP should be closely monitored for signs of infection and organ failure, and antibiotic use should be tailored to the individual patient's needs 6.