What are the management options for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis should be stratified based on disease severity, with all severe cases requiring intensive care unit management with full monitoring and systems support. 1

Initial Assessment and Classification

Disease Severity Assessment

• Classify pancreatitis as mild or severe using objective criteria:
  • Mild: 80% of cases, <5% mortality rate 1
  • Severe: 20% of cases, 95% of mortality occurs in this group 1

Predictors of Severity

• 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 of Mild Acute Pancreatitis

General Management

• Can be managed on general ward
• Basic monitoring: temperature, pulse, blood pressure, urine output
• Peripheral IV line for fluids
• Possible nasogastric tube
• Urinary catheter rarely needed 1

Fluid Resuscitation

• Aggressive fluid resuscitation is cornerstone of management
• Lactated Ringer's solution is preferred over Normal Saline
  • LR reduces severity by 31% and mortality by 62% compared to NS 2
  • LR shows significant reduction in SIRS at 24 hours 3

Antibiotics

• Do not administer antibiotics routinely in mild cases
• Only indicated for specific infections (chest, urine, bile, or cannula-related) 1

Imaging

• Routine CT scanning unnecessary unless clinical deterioration occurs 1
• Ultrasound should be performed early to identify gallstones 1

Management of Severe Acute Pancreatitis

Critical Care Management

• All patients with severe acute pancreatitis must be managed in HDU/ITU with full monitoring and systems support 1
• Required monitoring:
  • Peripheral venous access
  • Central venous line for fluid administration and CVP monitoring
  • Urinary catheter
  • Nasogastric tube
  • Regular arterial blood gas analysis
  • Hourly vital signs including pulse, BP, CVP, respiratory rate, oxygen saturation, urine output, temperature 1
• Swan-Ganz catheter if cardiocirculatory compromise exists 1

Fluid Resuscitation

• Adequate prompt fluid resuscitation is crucial
• Oxygen supplementation to maintain arterial saturation >95%
• IV fluids (crystalloid or colloid) to maintain urine output >0.5 ml/kg body weight
• Monitor with frequent CVP measurements 1

Antibiotics

• Evidence for prophylactic antibiotics is conflicting
• If used, intravenous cefuroxime is reasonable for efficacy and cost
• Maximum duration of 14 days 1
• Only indicated for confirmed infections or prophylaxis in severe cases 1

Imaging

• Dynamic CT scanning should be obtained within 3-10 days of admission
• Non-ionic contrast should be used
• Follow-up CT only if clinical deterioration or to detect asymptomatic complications before discharge 1

Nutritional Support

• If nutritional support is required, enteral route is preferred over parenteral 1
• Nasogastric feeding is feasible in up to 80% of cases 1
• Parenteral nutrition only if ileus persists for more than 5 days 1

Management of Gallstone Pancreatitis

ERCP Indications

• Urgent therapeutic ERCP indicated for:
  • Severe gallstone pancreatitis
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 1
• Best performed within first 72 hours after onset of pain
• All patients undergoing early ERCP require endoscopic sphincterotomy 1

Definitive Management

• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission 1

Management of Necrosis

• Patients with >30% pancreatic necrosis or smaller areas with suspected sepsis should undergo image-guided fine needle aspiration 1
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 1

Common Pitfalls to Avoid

1. Delayed fluid resuscitation - must be prompt and adequate
2. Using Normal Saline instead of Lactated Ringer's solution
3. Routine use of antibiotics in mild cases
4. Delayed ERCP in severe gallstone pancreatitis
5. Overreliance on parenteral rather than enteral nutrition
6. Failure to refer severe cases to specialist centers
7. Inadequate monitoring of severe cases outside ICU/HDU setting

Special Considerations

• Mortality should be <10% overall and <30% in severe pancreatitis 1
• Every hospital should have a single nominated clinical team to manage all patients with acute pancreatitis 1
• Management in or referral to a specialist unit is necessary for patients with extensive necrotizing pancreatitis 1