What is the treatment approach for pancreatitis?

Treatment Approach for Pancreatitis

The treatment of pancreatitis should be stratified based on severity, with mild cases requiring supportive care and severe cases needing intensive monitoring and intervention. 1

Initial Assessment and Classification

• Diagnose acute pancreatitis when at least two of the following are present:

  • Characteristic abdominal pain
  • Amylase/lipase ≥3 times upper limit of normal
  • Characteristic findings on imaging 1

• Classify severity:

  • Mild (80% of cases, <5% mortality): No organ failure or local complications
  • Severe (20% of cases, 95% of deaths): Presence of organ failure and/or local complications 2, 1

Treatment of Mild Acute Pancreatitis

Fluid Resuscitation

• Provide adequate intravenous fluids (crystalloids preferred) 2, 1
• Target urine output >0.5 ml/kg/h and arterial saturation >95% 1
• Monitor vital signs (temperature, pulse, blood pressure) 2

Nutrition

• Initiate early oral feeding (within 24 hours) as tolerated 2, 1
• Avoid nil per os (NPO) status as it can prolong hospital stay 1

Antibiotics

• Do not administer prophylactic antibiotics 2, 1
• Only use antibiotics for specific infections (chest, urine, bile, or cannula-related) 2

Imaging

• Routine CT scanning is unnecessary unless clinical deterioration occurs 2, 1
• Perform abdominal ultrasound to detect gallstones 1

Treatment of Severe Acute Pancreatitis

Intensive Care Management

• Admit to ICU or HDU for close monitoring 2, 1
• Provide peripheral venous access, central venous line, urinary catheter, and nasogastric tube 2
• Monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 2
• Consider Swan-Ganz catheter for cardiocirculatory compromise 2
• Perform regular arterial blood gas analysis 2

Fluid Resuscitation

• Implement goal-directed fluid therapy with crystalloids 2, 1
• Avoid overaggressive fluid resuscitation which can lead to respiratory complications 1

Nutrition

• For patients unable to tolerate oral feeding, use enteral nutrition (either nasogastric or nasojejunal) rather than parenteral nutrition 2, 1
• Avoid delayed oral feeding as it can worsen outcomes 1

Antibiotics

• Consider prophylactic antibiotics in severe cases with pancreatic necrosis 2
• Intravenous cefuroxime is a reasonable choice 2

Imaging and Intervention

• Perform dynamic CT scan with IV contrast between 3-10 days after admission 2, 1
• Necrotic tissue generally does not require treatment unless infected 1
• For infected necrosis, intervention is needed to debride all cavities containing necrotic material 1

Management of Specific Types of Pancreatitis

Biliary Pancreatitis

• Perform ERCP in patients with concomitant cholangitis or high suspicion of persistent common bile duct stone 2, 1
• Do not perform routine ERCP in the absence of cholangitis 2, 1
• Perform cholecystectomy during the same hospitalization or within two weeks 2, 1

Alcoholic Pancreatitis

• Provide alcohol counseling during initial admission 2, 1

Chronic Pancreatitis with Exocrine Insufficiency

• Consider pancreatic enzyme replacement therapy (PERT) like pancrelipase for patients with exocrine pancreatic insufficiency 3
• Dosage: 72,000 lipase units per main meal and 36,000 lipase units per snack 3

Common Pitfalls to Avoid

1. Delaying fluid resuscitation in the early phase of acute pancreatitis
2. Keeping patients nil per os unnecessarily, which can prolong hospital stay
3. Routine use of prophylactic antibiotics in mild pancreatitis
4. Overreliance on parenteral nutrition when enteral nutrition is possible
5. Delayed cholecystectomy in biliary pancreatitis, increasing risk of recurrent attacks
6. Routine ERCP in biliary pancreatitis without cholangitis
7. Overaggressive fluid resuscitation leading to respiratory complications

By following these evidence-based guidelines, clinicians can optimize outcomes and reduce mortality in patients with acute pancreatitis.