What is the diagnosis and treatment for pancreatitis (inflammation of the pancreas)?

From the Guidelines

Pancreatitis should be diagnosed and treated based on its severity, with acute cases typically managed with supportive care including pain management, intravenous fluids, and bowel rest, while severe cases may require intensive care monitoring and surgical intervention, as recommended by the 2019 WSES guidelines 1. The diagnosis of pancreatitis involves identifying the underlying cause, such as gallstones or alcohol consumption, and assessing the severity of the disease using classification systems like the 2012 revision of the Atlanta classification 1.

• The treatment of acute pancreatitis focuses on supportive care, including:
  • Pain management with medications like morphine or hydromorphone
  • Intravenous fluids, typically crystalloids at 5-10 mL/kg/hr initially
  • Bowel rest
• Most patients can begin oral intake once pain improves and nausea subsides, usually within 3-5 days
• Severe cases may require intensive care monitoring and surgical intervention, such as percutaneous drainage or minimally invasive surgical strategies, as recommended by the 2019 WSES guidelines 1
• The use of antibiotics is recommended to treat infected severe acute pancreatitis, with serum measurements of procalcitonin (PCT) valuable in predicting the risk of developing infected pancreatic necrosis 1
• Chronic pancreatitis involves ongoing inflammation leading to permanent damage, with treatment centered on pain control, enzyme replacement therapy, and managing complications like diabetes, as recommended by the ESPEN guidelines on enteral nutrition 1
• Nutritional support is important, with a low-fat diet recommended for chronic cases, and enzyme supplements available to manage steatorrhoea and malabsorption
• Enteral nutrition (EN) is indicated if patients cannot ingest sufficient calories, and parenteral nutrition (PN) is only indicated when EN is not possible, as recommended by the ESPEN guidelines on enteral nutrition 1

From the FDA Drug Label

INDICATIONS AND USAGE CREON is indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients. (1)

The FDA drug label does not answer the question.

From the Research

Diagnosis of Pancreatitis

• The diagnosis of pancreatitis is based on clinical symptoms, increased serum amylase or lipase levels, and/or characteristic findings on computed tomography 2
• Serum levels of amylase, visual analogue pain scores, and volume overload are assessed at baseline and 2,8, and 24 hours after endoscopic retrograde cholangiopancreatography (ERCP) to determine the incidence of post-ERCP pancreatitis 3

Treatment of Pancreatitis

• Aggressive fluid resuscitation with lactated Ringer's solution is recommended for initial management of acute pancreatitis 4, 5
• Goal-directed fluid resuscitation does not significantly reduce the incidence of systemic inflammatory response syndrome (SIRS) or levels of C-reactive protein (CRP) after 24 hours, but lactated Ringer's solution reduces systemic inflammation compared with normal saline 4
• Patients with severe acute pancreatitis should be transferred to a medical facility where intensive respiratory and cardiovascular management, interventional treatment, blood purification therapy, and nutritional support are available 6
• Enteral feeding is superior to parenteral nutrition for nutritional support in patients with severe acute pancreatitis 6, 5, 2
• Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with severe acute pancreatitis, but routine use of prophylactic antibiotics in acute pancreatitis is not recommended 6, 5
• Cholecystectomy during the same admission is recommended for patients with biliary pancreatitis to prevent future acute pancreatitis episodes 5

Management of Acute Pancreatitis

• Patients presenting with acute pancreatitis should be evaluated clinically for signs and symptoms of organ failure to appropriately triage 5
• Initial management should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline 5
• Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged 5
• Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis, and infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy 2