What is the management of pancreatitis?

Management of Acute Pancreatitis

Acute pancreatitis should be managed with early Lactated Ringer's solution as first-line fluid therapy, early oral feeding within 24 hours as tolerated, multimodal pain management, and monitoring in HDU/ICU for severe cases with no prophylactic antibiotics for sterile necrosis. 1

Initial Assessment and Diagnosis

• Diagnosis requires characteristic abdominal pain and lipase >3 times upper limit of normal 1
• Assess severity within 48 hours using:
  • Clinical impression
  • Laboratory markers (C-reactive protein >150 mg/L)
  • Scoring systems (BISAP or APACHE II) 1
• Identify etiology (gallstones, alcohol, hypertriglyceridemia, medications, post-ERCP, trauma, hypercalcemia, anatomical variations, tumors) 1

Fluid Resuscitation

• Lactated Ringer's solution is the first-line fluid for acute pancreatitis 1, 2

  • Associated with reduced 1-year mortality compared to normal saline (adjusted odds ratio, 0.61; 95% CI, 0.50-0.76) 2
  • Significantly reduces systemic inflammatory response syndrome (SIRS) after 24 hours compared to normal saline (84% reduction vs 0%, P=0.035) 3
  • Reduces C-reactive protein levels compared to normal saline (51.5 vs 104 mg/dL, P=0.02) 3

• Target moderate fluid resuscitation with:

  • Urine output >0.5 mL/kg/h
  • Arterial saturation >95%
  • Monitor hematocrit, BUN, creatinine, and lactate 1

Monitoring and Supportive Care

• For severe pancreatitis, manage in HDU/ICU with:
  • Hourly vital signs
  • Central venous pressure monitoring
  • Oxygen saturation
  • Urine output
  • Temperature 1
• Provide supplemental oxygen to maintain arterial saturation >95% 1
• Consider Swan-Ganz catheter for cardiocirculatory compromise 1
• Maintain strict asepsis when placing invasive monitoring equipment 1

Nutrition Management

• Initiate early oral feeding within 24 hours as tolerated 1
• If oral feeding not possible, start enteral nutrition within 24-72 hours using either nasogastric or nasojejunal routes 1
• Avoid parenteral nutrition unless enteral routes are not possible

Pain Management

• Implement multimodal analgesia approach:
  • Morphine or Dilaudid as first-line opioid analgesics
  • Consider epidural analgesia for severe cases requiring high doses of opioids 1

Imaging

• Perform contrast-enhanced CT scan for severity assessment in predicted severe disease
• Optimal timing: 3-10 days after admission
• Use CT severity index to predict complications and mortality 1
• Avoid routine follow-up CT scans unless clinical status deteriorates 1

Management of Biliary Pancreatitis

• Urgent ERCP (within 24 hours) indicated for:
  • Concomitant cholangitis
  • Persistent common bile duct obstruction
  • Severe gallstone pancreatitis with increasingly deranged liver function tests 1
• Always perform ERCP under antibiotic cover 1
• Cholecystectomy timing:
  • Perform during same hospital admission for mild cases
  • Significantly reduces mortality and gallstone-related complications (OR, 0.24; 95% CI, 0.09-0.61)
  • Reduces readmission for recurrent pancreatitis (OR, 0.25; 95% CI, 0.07-0.90) 1
  • If not possible during admission, schedule within two weeks 1

Antibiotic Management

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

Management of Complications

• Monitor for development of:
  • Pancreatic pseudocysts
  • Walled-off necrosis
  • Disconnected pancreatic duct syndrome 1
• Assess for persistent symptoms requiring intervention after 4-8 weeks:
  • Ongoing pain and discomfort
  • Gastric outlet, biliary, or intestinal obstruction due to collections
  • Symptomatic or growing pseudocyst 1

Additional Considerations

• Provide brief alcohol intervention during admission for alcohol-related pancreatitis 1
• Implement strict glucose control with insulin therapy for hyperglycemia 1
• Avoid specific drug therapies (antiproteases, antisecretory agents) as they have not shown benefit in large randomized studies 1

Common Pitfalls to Avoid

• Overaggressive fluid resuscitation in predicted severe disease may be deleterious 4
• Delaying oral feeding unnecessarily
• Using prophylactic antibiotics in sterile necrosis
• Delaying cholecystectomy in gallstone pancreatitis
• Routine use of follow-up CT scans without clinical indication