From the Guidelines
Acute pancreatitis requires prompt medical attention, with treatment typically involving hospitalization for pain management, fluid resuscitation, and bowel rest, as recommended by the 2019 WSES guidelines 1.
Diagnosis and Severity Classification
The diagnosis of acute pancreatitis requires at least two of the three following criteria: abdominal pain consistent with the disease, biochemical evidence of pancreatitis, and characteristic findings from abdominal imaging 1. The Revised Atlanta Classification (RAC) and Determinant-Based Classification of Acute Pancreatitis Severity (DBC) are two new classification systems that have been shown to accurately classify the severity of acute pancreatitis, with the RAC being a broader overview that includes severity classification, diagnosis, and definition of local complications 1.
Treatment and Management
Patients with acute pancreatitis should receive aggressive IV fluid therapy with lactated Ringer's solution at 5-10 mL/kg/hr initially, then adjusted based on response, as well as pain control with opioid analgesics like morphine or hydromorphone 1. Most patients should avoid oral intake for 24-48 hours, with gradual reintroduction of clear liquids once pain improves and inflammatory markers decrease. Nutritional support via enteral feeding may be needed if oral intake cannot be resumed within 5-7 days 1.
- Key aspects of management include:
- Early fluid resuscitation
- IV pain medications
- Mechanical ventilation for severe cases
- Enteral nutrition (oral, NG, or NJ) or parenteral nutrition if not tolerated
- The use of prophylactic antibiotics is not recommended unless infection is suspected, and antibiotics should only be used to treat infected severe acute pancreatitis 1.
Monitoring and Complications
Patients with severe acute pancreatitis should be admitted to an intensive care unit whenever possible, and those with persistent organ failure should be closely monitored for complications like necrosis, pseudocysts, or organ failure 1. The diagnosis of infected severe acute pancreatitis can be challenging, but can be aided by the use of procalcitonin (PCT), CT- or EUS-guided fine-needle aspiration (FNA) for Gram stain and culture, and endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis and common bile duct obstruction 1.
From the Research
Diagnosis of Acute Pancreatitis
- Acute pancreatitis is diagnosed based on two of the following: upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 2
- Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated for diagnosis 2
Management of Acute Pancreatitis
- Initial management should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline 3, 4
- Routine use of prophylactic antibiotics in acute pancreatitis is not recommended, nor is urgent endoscopic retrograde cholangiopancreatography in the absence of concomitant acute cholangitis 3, 5
- Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged 3, 5
- Cholecystectomy during the same admission of biliary pancreatitis should be performed in order to prevent future acute pancreatitis episodes 3
Treatment and Outcomes
- Patients with acute pancreatitis should be evaluated clinically for signs and symptoms of organ failure in order to appropriately triage 3
- Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis 4
- Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis 4
- However, another study found no significant difference in outcomes between patients resuscitated with lactated Ringer's solution and those who received normal saline 6