What is the treatment for acute pancreatitis?

From the Guidelines

The treatment for acute pancreatitis primarily involves supportive care, with a focus on early oral feeding, adequate pain control, and fluid resuscitation, as recommended by the most recent guidelines 1. The initial management includes aggressive intravenous fluid resuscitation, but the recent study by 1 suggests that aggressive intravenous hydration may not be beneficial and could potentially increase the risk of fluid overload and mortality in non-severe acute pancreatitis.

• Early oral feeding as tolerated is recommended, with enteral nutrition via nasojejunal tube preferred over parenteral nutrition if oral feeding isn't possible after 3-5 days 1.
• Adequate pain control with opioid analgesics like morphine or hydromorphone is essential.
• Antibiotics are not routinely recommended unless there's evidence of infection, as stated in the guidelines by 1 and 1.
• Severe cases may require intensive care monitoring, with treatment of complications like pseudocysts or infected necrosis through minimally invasive approaches when possible.
• The underlying cause should be addressed, such as gallstone removal for biliary pancreatitis or alcohol cessation counseling, as recommended by 1 and 1. This approach targets the pathophysiology of pancreatitis by allowing the inflamed pancreas to rest while maintaining nutrition and preventing complications from systemic inflammatory response. Key considerations include:
• Fluid resuscitation should be goal-directed, with careful monitoring of the patient's response to avoid fluid overload 1.
• Nutritional support should be individualized, with enteral nutrition preferred over parenteral nutrition whenever possible 1.
• Prophylactic antibiotics should not be used routinely, but rather reserved for patients with evidence of infection or at high risk of developing infected necrosis 1.

From the Research

Treatment Overview

The treatment for acute pancreatitis primarily involves fluid resuscitation, with the goal of preventing organ failure and managing the condition's severity.

Fluid Resuscitation Approaches

• Intravenous fluid resuscitation is the cornerstone of early treatment for acute pancreatitis, as stated in 2 and 3.
• The optimal rate, type, and goal of resuscitation remain unclear, but crystalloids are currently recommended for management, as mentioned in 3.
• Lactated Ringer's solution is preferred based on animal studies, clinical trials, and meta-analyses, as indicated in 2.
• A study comparing normal saline versus Lactated Ringer's solution for fluid resuscitation in patients with mild acute pancreatitis found that Lactated Ringer's solution was superior in reducing systemic inflammatory response syndrome (SIRS) in the first 24 hours, as reported in 4.

Aggressive vs. Moderate Fluid Resuscitation

• Early aggressive hydration is widely recommended, but evidence for this practice is limited, as noted in 5.
• A randomized trial found that early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes, as stated in 5.
• Moderate fluid resuscitation may be a safer approach, with a lower risk of fluid overload, as suggested in 5.

Alternative Resuscitation Methods

• Naso-jejunal fluid resuscitation using oral hydration solution is feasible and equally efficacious as intravenous fluid resuscitation with Ringer's lactate in select patients with severe acute pancreatitis, as reported in 6.
• This approach may be considered as an alternative to traditional intravenous fluid resuscitation, as mentioned in 6.