What is the treatment for pancreatitis?

Treatment of Pancreatitis

The treatment of pancreatitis should be stratified based on disease severity, with mild cases managed conservatively with supportive care and severe cases requiring intensive monitoring, aggressive fluid resuscitation, and specialized interventions. 1

Initial Assessment and Classification

• Diagnose using:

  • Laboratory markers: Lipase, amylase, white blood cell count, C-reactive protein, procalcitonin (most sensitive for pancreatic infection) 1
  • Imaging: CT with IV contrast, MRI, or endoscopic ultrasound 1

• Classify severity:

  • Mild: No organ failure or local complications
  • Moderately severe: Transient organ failure (<48 hours) or local complications
  • Severe: Persistent organ failure (>48 hours) 1

Treatment Algorithm by Severity

Mild Acute Pancreatitis

1. Diet:

   • Regular diet with advancement as tolerated 1
   • No need for routine fasting

2. Pain Management:

   • Oral pain medications as needed 1

3. Monitoring:

   • Routine vital signs 1
   • No need for intensive monitoring

4. Antibiotics:

   • Do not administer prophylactic antibiotics as there is no evidence they affect outcomes or reduce septic complications 1
   • Only treat specific infections if they occur (chest, urinary tract, etc.) 1

5. Imaging:

   • No routine CT scanning unless clinical deterioration occurs 1

Moderately Severe Acute Pancreatitis

1. Nutrition:

   • Enteral nutrition (oral, nasogastric, or nasojejunal)
   • Parenteral nutrition only if enteral feeding not tolerated 1

2. Pain Management:

   • IV pain medications 1

3. Fluid Resuscitation:

   • IV fluids to maintain hydration
   • Lactated Ringer's solution preferred over normal saline (reduces systemic inflammation) 2, 3

4. Monitoring:

   • Continuous vital signs monitoring
   • Regular assessment of hematocrit, BUN, creatinine 1

Severe Acute Pancreatitis

1. Setting:

   • All patients with severe acute pancreatitis must be managed in an ICU or HDU setting with full monitoring and systems support 1

2. Fluid Resuscitation:

   • Early aggressive fluid resuscitation with Lactated Ringer's solution 1, 4
   • Monitor using central venous pressure in appropriate patients 1
   • Target urine output >0.5 mL/kg/hour 1

3. Respiratory Support:

   • Supplemental oxygen to maintain saturation >95% 1
   • Mechanical ventilation if needed 1

4. Nutrition:

   • Enteral nutrition preferred (oral, nasogastric, or nasojejunal)
   • Parenteral nutrition only if enteral feeding not tolerated 1

5. Antibiotics:

   • Do not use routine prophylactic antibiotics 1
   • Only treat confirmed infected pancreatic necrosis 1
   • For infected necrosis, use one of the following based on patient factors:
     • Meropenem 1g q6h by extended infusion
     • Imipenem/cilastatin 500mg q6h by extended infusion
     • For MDR pathogens: Imipenem/cilastatin-relebactam, meropenem/vaborbactam, or ceftazidime/avibactam + metronidazole 1

6. Monitoring:

   • Continuous vital signs monitoring
   • Regular arterial blood gas analysis
   • Central venous pressure monitoring 1

7. Imaging:

   • Dynamic CT scan with IV contrast within 3-10 days of admission 1
   • Follow-up CT only if clinical deterioration occurs 1

Management of Gallstone Pancreatitis

1. ERCP Indications:

   • Urgent ERCP with sphincterotomy within 72 hours for:
     • Severe gallstone pancreatitis
     • Cholangitis
     • Jaundice
     • Dilated common bile duct 1

2. Cholecystectomy Timing:

   • For mild gallstone pancreatitis: Perform within 2-4 weeks, preferably during same hospital admission 1
   • For severe gallstone pancreatitis: Delay until inflammatory process has subsided 1

Management of Complications

1. Pancreatic Necrosis:

   • For persistent symptoms with >30% pancreatic necrosis or clinical suspicion of sepsis: Perform image-guided fine needle aspiration for culture 1
   • For infected necrosis: Complete debridement of all cavities containing necrotic material 1

2. Pancreatic Insufficiency:

   • For exocrine pancreatic insufficiency: Pancrelipase (pancreatic enzyme replacement therapy) 5

Pitfalls and Caveats

1. Fluid Resuscitation:

   • Avoid over-aggressive fluid resuscitation in severe pancreatitis as it may be deleterious 4
   • Lactated Ringer's solution is superior to normal saline for reducing systemic inflammation 2, 3

2. Antibiotic Use:

   • Prophylactic antibiotics do not reduce mortality or morbidity in acute pancreatitis 1
   • Reserve antibiotics for confirmed infected necrosis or specific infections 1

3. Nutrition:

   • Early enteral nutrition is preferred over parenteral nutrition 1
   • Nasogastric route is effective in approximately 80% of cases 1

4. Timing of Interventions:

   • Early ERCP (within 72 hours) is beneficial only for severe gallstone pancreatitis with biliary obstruction or cholangitis 1
   • Delay cholecystectomy in severe cases until inflammation resolves 1