From the Guidelines
Management of non-alcoholic pancreatitis involves both supportive care and addressing the underlying cause, with a focus on goal-directed fluid resuscitation, early oral feeding, and enteral rather than parenteral nutrition, as recommended by the American Gastroenterological Association Institute guideline on initial management of acute pancreatitis 1.
Key Management Strategies
- Initial management includes bowel rest, intravenous fluid resuscitation with lactated Ringer's solution, and pain control with opioid analgesics.
- Nutritional support should be initiated early, preferably with enteral nutrition via nasojejunal tube if oral intake isn't possible within 48-72 hours.
- For gallstone pancreatitis, early ERCP (within 24-48 hours) is recommended if there's cholangitis or persistent biliary obstruction, followed by cholecystectomy during the same hospitalization if possible, as supported by the AGA Institute medical position statement on acute pancreatitis 1.
Specific Causes and Management
- Hypertriglyceridemia-induced pancreatitis requires aggressive triglyceride lowering with insulin infusion or plasmapheresis for levels >1000 mg/dL.
- Drug-induced pancreatitis necessitates discontinuation of the offending medication.
- Autoimmune pancreatitis responds well to steroid therapy, typically prednisone 40 mg daily for 4 weeks followed by a gradual taper over 2-3 months.
- Genetic causes like hereditary pancreatitis require genetic counseling and long-term monitoring for complications.
Nutrition in Acute Pancreatitis
- The European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines on nutrition in acute pancreatitis emphasize the importance of nutritional support in patients with acute pancreatitis, particularly those with a prolonged and complicated course 1.
- Early feeding is not thought to stimulate the exocrine pancreatic secretion and autodigestive processes, and nutritional deficiencies can occur in patients with a prolonged course of acute necrotizing pancreatitis.
From the Research
Non-Alcoholic Causes of Pancreatitis
The management strategies for non-alcoholic causes of pancreatitis involve various approaches, including:
- Supportive care, such as pancreatic rest and lifestyle changes 2
- Medications, including fibrates, n-3 polyunsaturated fatty acids, and nicotinic acid, for hypertriglyceridemia-induced pancreatitis 2
- Risk stratification tools to guide clinical decision making 3
- Intravenous fluid resuscitation, feeding, prophylactic antibiotics, probiotics, and timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis 3
Management Strategies
The management of severe acute pancreatitis (SAP) involves:
- Severity prediction, fluid resuscitation, analgesic administration, nutrition, and endoscopic intervention 4
- Early enteral tube-feeding or on-demand oral feeding 4
- Endoscopic transmural drainage followed by necrosectomy for symptomatic or infected walled-off pancreatic necrosis 4
- A step-up, minimally invasive drainage/debridement approach for patients with infected pancreatic necrosis 4
Recent Treatment Strategies
Recent updates in the treatment of acute pancreatitis include:
- Goal-directed and non-aggressive hydration with lactated Ringer's solution 5
- Early enteral feeding 5
- Procalcitonin-based algorithm of antibiotic use to distinguish between inflammation and infection 5
- Urgent ERCP for patients with gallstone pancreatitis and cholangitis, but not for those without cholangitis 5
- Convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis 5
Causes of Non-Alcoholic Pancreatitis
Other important causes of non-alcoholic pancreatitis include: