What are the guidelines for managing pancreatitis?

Management Guidelines for Acute Pancreatitis

Patients with acute pancreatitis should be managed according to severity, with all severe cases requiring high dependency or intensive care unit admission with full monitoring and systems support to reduce mortality and morbidity. 1

Diagnosis and Initial Assessment

• Diagnosis requires at least two of the following criteria:

  • Characteristic upper abdominal pain
  • Serum amylase/lipase ≥3× upper limit of normal
  • Characteristic findings on cross-sectional imaging 2

• Lipase is preferred over amylase for diagnosis when available 1

• Determine etiology within 48 hours of admission:

  • Transabdominal ultrasound for gallstones within 24 hours
  • Serum triglycerides, liver function tests, calcium levels
  • No more than 20% of cases should be classified as idiopathic 1

• Severity assessment within 48 hours using:

  • Clinical impression of severity
  • Obesity
  • APACHE II score in first 24 hours
  • C-reactive protein >150 mg/L
  • Glasgow score ≥3
  • Persistent organ failure after 48 hours 1

Management Based on Severity

Mild Acute Pancreatitis (80% of cases)

• General ward management with basic monitoring
• IV fluid resuscitation (Ringer's lactate preferred over normal saline) 3
• Analgesia (multimodal approach to reduce opioid requirements) 3
• No routine antibiotics unless specific infections occur 1
• No routine CT scanning unless clinical deterioration 1
• Early oral feeding with normal "on-demand" diet improves recovery and reduces hospital stay 3

Severe Acute Pancreatitis (20% of cases)

• HDU/ICU admission with full monitoring and systems support 1

• Minimum requirements:

  • Peripheral venous access
  • Central venous line for fluid administration and CVP monitoring
  • Urinary catheter
  • Nasogastric tube
  • Regular monitoring of vital signs, oxygen saturation, and fluid balance
  • Arterial blood gas analysis 1

• Consider Swan-Ganz catheter for cardiocirculatory compromise 1

• CT scan with contrast enhancement within 3-10 days of admission 1

• CT scan required for patients with:

  • Persistent organ failure
  • Signs of sepsis
  • Clinical deterioration 6-10 days after admission 1

Nutritional Support

• If nutritional support is required, enteral route should be used when tolerated 1
• Nasogastric feeding is effective in 80% of cases 1
• Parenteral nutrition only when enteral feeding not tolerated 2

Antibiotic Use

• No consensus on prophylactic antibiotics for pancreatic necrosis 1
• If used, limit antibiotic prophylaxis to 14 days maximum 1
• Procalcitonin may help distinguish inflammation from infection 4
• Targeted antibiotic use for confirmed infections 1

Management of Gallstone Pancreatitis

• Urgent ERCP (within 72 hours) for:
  • Predicted or actual severe gallstone pancreatitis
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 1
• Endoscopic sphincterotomy for all patients undergoing early ERCP 1
• Definitive gallstone management during same hospital admission or within two weeks 1

Management of Pancreatic Necrosis

• Image-guided fine needle aspiration for:
  • Persistent symptoms with >30% pancreatic necrosis
  • Smaller areas of necrosis with clinical suspicion of sepsis 1
• Infected necrosis requires complete debridement of all cavities containing necrotic material 1
• Delay drainage as much as possible to reduce number of procedures 3
• Referral to specialist unit for patients with extensive necrotizing pancreatitis 1

Audit Standards

• Overall mortality should be <10%, and <30% in severe cases
• Correct diagnosis within 48 hours of admission
• Severity stratification within 48 hours
• Etiology determined in at least 80% of cases 1

Common Pitfalls to Avoid

• Overaggressive fluid resuscitation (moderate resuscitation is preferred) 3
• Prolonged fasting (early feeding is beneficial) 3, 4
• Routine use of antibiotics in mild cases 1
• Delayed referral of severe cases to specialist units 1
• Inadequate monitoring of patients with severe disease 1
• Performing unnecessary ERCP in gallstone pancreatitis without cholangitis 4

By following these guidelines, clinicians can optimize outcomes for patients with acute pancreatitis, reducing morbidity and mortality through appropriate early management and timely interventions.