What is the management of acute pancreatitis?

Management of Acute Pancreatitis

Moderate fluid resuscitation with Lactated Ringer's solution at 5-10 ml/kg/h is the cornerstone of acute pancreatitis management, as it reduces mortality compared to aggressive fluid administration. 1

Initial Assessment and Management (First 72 Hours)

Fluid Resuscitation

• Begin with 10 ml/kg bolus for hypovolemic patients, then maintain at 5-10 ml/kg/h
• Use Lactated Ringer's solution as the preferred fluid
• Reassess fluid requirements at 12,24,48, and 72 hours based on:
  • Urine output
  • Heart rate and blood pressure normalization
  • Arterial oxygen saturation
  • Laboratory markers 1

Nutrition

• Start oral feeding within 24 hours if tolerated
• If oral feeding not possible, initiate enteral nutrition within 24-72 hours via nasogastric or nasojejunal routes
• Avoid parenteral nutrition unless ileus persists >5 days
• Use diet rich in carbohydrates and proteins but low in fats 1

Pain Management

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

Oxygen Support

• Provide supplemental oxygen to maintain arterial saturation >95%
• Use continuous oxygen saturation monitoring 1

Severity Assessment and Monitoring

• Assess severity within 48 hours using:
  • Clinical impression
  • Laboratory markers (elevated C-reactive protein)
  • Scoring systems (BISAP, APACHE II, Glasgow score)
  • Presence of organ failure (respiratory, circulatory, or renal) 1
• Manage severe acute pancreatitis in high dependency or intensive care units 1
• Perform initial ultrasound to evaluate for gallstones 1
• Consider dynamic CT scanning within 3-10 days for severe cases 1

Management of Complications

Infection Management

• 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 when indicated
• Do not use prophylactic antibiotics for sterile necrosis 1

Local Complications

• Monitor for development of:
  • Pancreatic pseudocysts
  • Walled-off necrosis
  • Disconnected pancreatic duct syndrome 1
• For infected necrotizing pancreatitis, prefer minimally invasive endoscopic step-up approaches over surgical options 2

Convalescent Management

• Perform cholecystectomy during the same hospital admission for gallstone pancreatitis 1
• Provide brief alcohol intervention for alcoholic pancreatitis 1
• Administer thiamine supplementation to prevent Wernicke's encephalopathy in alcoholics 1
• Correct electrolyte abnormalities (potassium, magnesium, phosphate) 1
• Avoid routine follow-up CT scans unless clinical status deteriorates 1

Important Considerations and Pitfalls

Mortality Risk Factors

• Early deaths (within first week) typically result from multiple organ failure
• Later deaths are usually due to infectious complications, particularly infected necrosis
• Overall mortality should be <10%, and <30% in severe cases 3

Common Pitfalls to Avoid

1. Overaggressive fluid resuscitation - can increase mortality risk
2. Delayed enteral nutrition - early feeding improves outcomes
3. Prophylactic antibiotics for sterile necrosis - not recommended
4. Delayed cholecystectomy in gallstone pancreatitis - should be done during same admission
5. Overreliance on parenteral nutrition - enteral is preferred when possible
6. Routine use of ERCP - only indicated for gallstone pancreatitis with cholangitis 1, 4

The management approach has evolved significantly in recent years, with a shift from aggressive hydration to goal-directed moderate fluid resuscitation, early enteral feeding, avoidance of prophylactic antibiotics, and minimally invasive approaches for infected necrosis 5.