What is the management of pancreatitis?

Management of Pancreatitis

The management of pancreatitis requires a stepped approach focusing on severity assessment, fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, and appropriate interventions for gallstone pancreatitis including timely ERCP and cholecystectomy. 1

Initial Assessment and Diagnosis

• Assess severity within 48 hours using:
  • Clinical impression
  • Laboratory markers
  • Scoring systems (BISAP, APACHE II, Glasgow score)
  • Presence of organ failure 1
• Perform initial ultrasound to evaluate for gallstones
• Consider dynamic CT scanning within 3-10 days for severe cases 1

Fluid Resuscitation

• Implement moderate fluid resuscitation as the cornerstone of early treatment 1, 2
• Use Lactated Ringer's solution as the preferred fluid type, which has been shown to reduce systemic inflammation compared to normal saline 1, 3, 4
• Recent evidence from 2023 demonstrates that Lactated Ringer's solution is associated with lower 1-year mortality compared to normal saline (adjusted odds ratio 0.61) 3

Nutritional Support

• Initiate early enteral nutrition within 24-72 hours via nasogastric or nasojejunal tube 1
• Prefer enteral over parenteral nutrition unless ileus persists for more than 5 days 1
• Provide a diet rich in carbohydrates and proteins but low in fats, with approximately 60 grams of protein per day 1

Management of Gallstone Pancreatitis

• For gallstone pancreatitis with cholangitis, jaundice, dilated common bile duct, or severe disease:
  • Perform urgent ERCP within 24 hours 1
  • Perform endoscopic sphincterotomy for all patients undergoing early ERCP 1
• For mild gallstone pancreatitis:
  • Perform laparoscopic cholecystectomy with operative cholangiography during the same hospital admission 1

Infection Management

• Follow a stepped approach for infected necrosis, starting with percutaneous drainage 1
• Use antibiotics only for documented infections:
  • Maximum duration of 14 days for infected necrosis
  • Select broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms when indicated 1
• Avoid prophylactic antibiotics for sterile necrosis 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

Supportive Care

• Provide supplemental oxygen to maintain arterial saturation >95% with continuous monitoring 1
• Implement strict glucose control using insulin therapy for hyperglycemia 1
• Correct electrolyte abnormalities, particularly potassium, magnesium, and phosphate 1
• Provide thiamine supplementation to prevent Wernicke's encephalopathy, especially in chronic alcoholics 1

Follow-up and Surveillance

• Schedule regular follow-up every 6-12 months to evaluate:
  • Pain control
  • Nutritional status
  • Development of complications
  • Quality of life 1
• For alcoholic pancreatitis:
  • Provide brief alcohol intervention during hospital admission
  • Monitor for refeeding syndrome in malnourished patients 1
• For hereditary pancreatitis:
  • Refer to specialist centers for expert clinical assessment and genetic counseling
  • Implement pancreatic cancer surveillance starting at age 40 or 10 years earlier than the youngest affected relative
  • Use annual imaging with both MRI/MRCP and Endoscopic Ultrasound (EUS) 1

Common Pitfalls and Caveats

• Avoid aggressive fluid resuscitation in patients with predicted severe disease as it might be futile and potentially harmful 2
• Do not delay enteral nutrition; early implementation (within 24-72 hours) improves outcomes 1
• Do not use prophylactic antibiotics for sterile necrosis as this practice is not supported by evidence 1
• Recognize that while ERCP is beneficial in specific situations (cholangitis, severe gallstone pancreatitis), it is not indicated for all cases of pancreatitis 1