From the Guidelines
Acute interstitial pancreatitis should be managed with a supportive approach, focusing on pain management, aggressive intravenous fluid resuscitation, and early enteral nutrition, as recommended by the most recent guidelines 1. The treatment of acute interstitial pancreatitis is primarily focused on supportive care, with the goal of managing symptoms, preventing complications, and promoting recovery.
- Pain management is a crucial aspect of treatment, with medications like acetaminophen or opioids used as needed to control pain.
- Aggressive intravenous fluid resuscitation is also essential, typically starting with crystalloids at 5-10 mL/kg/hr initially, then adjusted based on response 1.
- Early enteral nutrition is recommended, with oral, NG, or NJ feeding used to support nutritional needs, and parenteral nutrition considered if enteral nutrition is not tolerated 1.
- Monitoring of vital signs, urine output, and laboratory values, including amylase, lipase, electrolytes, and renal function, is necessary to assess disease severity and guide treatment.
- The use of prophylactic antibiotics is not recommended for all patients with acute pancreatitis, but rather reserved for those with infected severe acute pancreatitis, as diagnosed by CT- or EUS-guided fine-needle aspiration (FNA) for Gram stain and culture, or by the presence of gas in the retroperitoneal area 1.
- Serum measurements of procalcitonin (PCT) may be valuable in predicting the risk of developing infected pancreatic necrosis, and can guide antibiotic therapy 1. The underlying cause of acute interstitial pancreatitis, such as gallstones, alcohol, or medications, should be identified and addressed to prevent recurrence.
- Most cases of acute interstitial pancreatitis resolve within 3-7 days with appropriate supportive care, but some patients may require ICU admission for severe disease 1.
From the Research
Definition and Diagnosis of Acute Interstitial Pancreatitis
- Acute interstitial pancreatitis is a form of acute pancreatitis, which is increasing in incidence across the world, and in all age groups 2.
- The diagnosis of acute pancreatitis requires two of upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 3.
- Contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically 4.
Management of Acute Interstitial Pancreatitis
- Intravenous fluid resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process 5.
- Lactated Ringer's solution is the preferred fluid type based on animal studies, clinical trials, and meta-analyses 6.
- Early aggressive fluid therapy among acute pancreatitis patients with predicted mild severity appears to have the highest benefit, whereas aggressive resuscitation in patients with predicted severe disease might be futile and deleterious 6.
- Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy 3.
Treatment and Complications
- Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible 4.
- Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension 4.
- In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 4.
- Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy 3.