From the Guidelines
The management of acute uncomplicated pancreatitis should focus on supportive care, including early oral feeding within 24 hours as tolerated, rather than keeping the patient nil per os, as recommended by the American Gastroenterological Association 1. The initial treatment includes aggressive intravenous fluid resuscitation, but the optimal rate of fluid resuscitation is still a topic of debate.
- A recent systematic review and meta-analysis compared clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis, but did not provide a clear recommendation on the optimal rate of fluid resuscitation 1.
- The American Gastroenterological Association suggests using goal-directed therapy for fluid management, but makes no recommendation on the type of fluid to use, such as normal saline or Ringer’s lactate 1.
- Pain control is essential, typically using opioid analgesics such as morphine or hydromorphone.
- Nutritional support should be initiated early, with enteral nutrition via nasojejunal tube preferred over parenteral nutrition if oral feeding is not possible, as recommended by the American Gastroenterological Association 1 and the European Society for Clinical Nutrition and Metabolism 1.
- Patients should be monitored for complications such as hypoxemia, hypotension, and organ failure using vital signs, urine output, and laboratory tests.
- The underlying cause of pancreatitis should be addressed, such as gallstone removal if biliary pancreatitis is present, with cholecystectomy recommended during the initial admission rather than after discharge 1.
- Prophylactic antibiotics are not recommended for uncomplicated pancreatitis as they do not improve outcomes and may lead to antibiotic resistance 1.
From the Research
Management of Acute Uncomplicated Pancreatitis
The management of acute uncomplicated pancreatitis involves several key components, including:
- Fluid resuscitation: Early aggressive intravenous hydration is recommended for acute pancreatitis treatment, although randomized trials have not consistently documented benefit 2, 3.
- Choice of fluid: Lactated Ringer's solution is the preferred fluid type based on animal studies, clinical trials, and meta-analyses 3, 4.
- Monitoring and adjustment: Fluid resuscitation should be adjusted according to the patient's clinical status, with monitoring of hematocrit, blood urea nitrogen, and creatinine levels 2, 5.
Fluid Resuscitation Strategies
Different fluid resuscitation strategies have been studied, including:
- Aggressive vs. standard hydration: A randomized trial found that aggressive hydration hastened clinical improvement in patients with mild acute pancreatitis 2.
- Naso-jejunal vs. intravenous fluid resuscitation: A randomized comparative study found that naso-jejunal fluid resuscitation with oral hydration solution was feasible and equally efficacious as intravenous fluid resuscitation with Ringer's lactate in predicted severe acute pancreatitis 6.
- Aggressive vs. moderate fluid resuscitation: A randomized trial found that early aggressive fluid resuscitation resulted in a higher incidence of fluid overload without improvement in clinical outcomes 5.
Key Findings
Key findings from the studies include:
- Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis 2.
- Lactated Ringer's solution reduces severity, mortality, and systemic and local complications in acute pancreatitis 4.
- Aggressive fluid resuscitation may increase the risk of fluid overload without improving clinical outcomes 5.