What is the management of pancreatitis?

Management of Acute Pancreatitis

Lactated Ringer's solution should be used as first-line fluid therapy for acute pancreatitis, with goal-directed resuscitation targeting urine output >0.5 mL/kg/h and arterial saturation >95%. 1

Initial Assessment and Resuscitation

Fluid Resuscitation

• Use Lactated Ringer's solution as the preferred crystalloid 1, 2
  • Reduces systemic inflammation compared to normal saline (84% reduction in SIRS vs 0%) 2
  • Associated with reduced 1-year mortality compared to normal saline (adjusted odds ratio 0.61) 3
• Target moderate fluid resuscitation with the following goals:
  • Urine output >0.5 mL/kg/h
  • Arterial saturation >95%
  • Monitor hematocrit, BUN, creatinine, and lactate 1

Monitoring

• All cases of severe acute pancreatitis should be managed in HDU or ICU with full monitoring 4
• Minimum monitoring requirements:
  • Hourly vital signs (pulse, blood pressure, respiratory rate)
  • Central venous pressure
  • Oxygen saturation
  • Urine output
  • Temperature 4, 1
• For cardiocirculatory compromise, consider Swan-Ganz catheter for advanced hemodynamic monitoring 4

Nutritional Support

• Begin early oral feeding within 24 hours as tolerated 1
• If oral feeding not possible, initiate enteral nutrition within 24-72 hours via nasogastric or nasojejunal routes 1

Pain Management

• Implement multimodal analgesia approach
• Use morphine or hydromorphone as first-line opioid analgesics
• Consider epidural analgesia for severe cases requiring high doses of opioids 1

Management of Gallstone Pancreatitis

ERCP Indications

• Urgent ERCP (within 24 hours) is indicated for:
  • Concomitant cholangitis
  • Persistent common bile duct obstruction
  • Severe gallstone pancreatitis with increasingly deranged liver function tests 4, 1
• Always perform ERCP under antibiotic cover 4

Cholecystectomy Timing

• For mild gallstone pancreatitis: perform cholecystectomy during the same hospital admission
  • Significantly reduces mortality and gallstone-related complications
  • Reduces readmission for recurrent pancreatitis 1
• If same-admission cholecystectomy not possible, schedule within two weeks 1

Antibiotic Management

• Do not use prophylactic antibiotics for sterile necrosis
• Use antibiotics only for documented infections
  • Maximum duration of 14 days for infected necrosis
  • Use broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms
  • Imipenem shows good penetration into pancreatic tissue 1

Imaging

• Perform contrast-enhanced CT scan for severity assessment in patients with predicted severe disease
  • Use CT severity index to predict complications and mortality
  • Timing: within 3-10 days of admission 4, 1
• Avoid routine follow-up CT scans unless clinical status deteriorates 1

Additional Interventions

• Provide supplemental oxygen to maintain arterial saturation >95% 1
• Implement strict glucose control with insulin therapy for hyperglycemia 1
• For alcoholic pancreatitis, provide brief alcohol intervention during admission 1

Pitfalls and Caveats

• Avoid aggressive fluid resuscitation in patients with predicted severe disease as it might be futile and potentially harmful 5
• Maintain strict asepsis when placing invasive monitoring equipment (central lines) to prevent secondary infection in pancreatic necrosis 4
• Do not use specific drug therapies (antiproteases, antisecretory agents) as they have not shown benefit in large randomized studies 1
• Early elevated hematocrit, blood urea nitrogen, or creatinine should prompt more intensive early resuscitation measures 6