From the Guidelines
The recommended treatment for acute pancreatitis primarily involves supportive care with aggressive intravenous fluid resuscitation, pain management, and nutritional support, with a strong emphasis on early oral feeding within 24 hours as tolerated, and enteral nutrition over parenteral nutrition if oral feeding is not possible, as suggested by the American Gastroenterological Association guidelines 1. The treatment approach should be tailored to the individual patient's needs, taking into account the severity of the disease and the presence of any complications.
- Key components of treatment include:
- Aggressive intravenous fluid resuscitation with crystalloid fluids, such as lactated Ringer's solution, at a rate of 5-10 mL/kg/hr for the first 24 hours, adjusted based on vital signs and urine output.
- Pain control with opioid analgesics, such as morphine or hydromorphone, as needed.
- Early enteral nutrition, preferably via nasogastric or nasojejunal tube, if oral intake is not tolerated, with the goal of starting nutrition within 24-48 hours.
- Treatment of the underlying cause, such as gallstones, with cholecystectomy typically performed during the same hospitalization.
- Alcohol cessation counseling for patients with alcohol-induced pancreatitis.
- The use of antibiotics is not routinely recommended unless there is evidence of infection or necrotizing pancreatitis, as suggested by the 2019 WSES guidelines 1.
- The diagnosis of infected pancreatitis can be challenging, but serum measurements of procalcitonin (PCT) may be valuable in predicting the risk of developing infected pancreatic necrosis, and CT-guided fine-needle aspiration (FNA) can confirm the diagnosis and guide antibiotic therapy 1.
From the Research
Diagnosis and Treatment of Acute Pancreatitis
The diagnosis of acute pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation 2. The most common etiologies include gallbladder disease and alcohol use.
Initial Management
The initial management of choice is fluid resuscitation and pain control 2. Recent data have suggested that more cautious fluid resuscitation in the first 24 hours might be more appropriate for some patients. Intravenous opiates are generally safe if used judiciously.
Fluid Resuscitation
Studies have compared the use of lactated Ringer's solution and normal saline for fluid resuscitation in acute pancreatitis. One study found that lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis 3. However, another study found no significant difference in the distribution of acute pancreatitis severity between patients who received lactated Ringer's solution and those who received normal saline 4.
Nutrition and Further Management
Nutrition plays an important role in treating patients with acute pancreatitis 5. The safety of early refeeding and importance in preventing complications from acute pancreatitis are addressed in the American College of Gastroenterology Guidelines. Patients with local complications should be referred to specialist tertiary centers to guide further management, which may include drainage and/or necrosectomy 6.
Key Considerations
- The diagnosis of acute pancreatitis requires two of the following three criteria: epigastric abdominal pain, an elevated lipase, and imaging findings of pancreatic inflammation 2
- The initial management of choice is fluid resuscitation and pain control 2
- Lactated Ringer's solution may reduce systemic inflammation compared with saline in patients with acute pancreatitis 3
- Nutrition plays an important role in treating patients with acute pancreatitis 5
- Patients with local complications should be referred to specialist tertiary centers to guide further management 6