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 targeted interventions for gallstone-related cases. 1

Initial Assessment and Severity Stratification

• 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

• Monitor for early severity indicators:

  • Elevated hematocrit
  • Rising blood urea nitrogen
  • Elevated creatinine 1

Fluid Resuscitation

• Administer Lactated Ringer's solution as the preferred fluid for resuscitation 1, 2, 3

  • Lactated Ringer's solution significantly reduces systemic inflammation compared to normal saline (84% reduction in SIRS at 24 hours) 3
  • Associated with lower 1-year mortality compared to normal saline (adjusted odds ratio 0.61) 2

• Use moderate rather than aggressive fluid resuscitation, as excessive fluid administration may be harmful in severe pancreatitis 1, 4

• Monitor response to fluid therapy through:

  • Urine output
  • Heart rate
  • Blood pressure
  • Hematocrit 1

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 (approximately 60g protein/day) 1
• Monitor for refeeding syndrome in malnourished patients, particularly alcoholics 1

Gallstone Pancreatitis Management

• Perform urgent ERCP within 24 hours for patients with:

  • Cholangitis
  • Jaundice
  • Dilated common bile duct
  • Severe gallstone pancreatitis 1

• Perform endoscopic sphincterotomy for all patients undergoing early ERCP 1

• Schedule laparoscopic cholecystectomy with operative cholangiography during the same hospital admission for mild gallstone pancreatitis 1

Infection Management

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

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

Supportive Care

• Provide supplemental oxygen to maintain arterial saturation >95% 1
• Implement strict glucose control using insulin therapy for hyperglycemia 1
• Correct electrolyte abnormalities (potassium, magnesium, phosphate) 1
• Provide thiamine supplementation, 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

• Provide brief alcohol intervention during hospital admission 1

• Refer patients with hereditary pancreatitis to specialist centers for:

  • Expert clinical assessment
  • Genetic counseling
  • Secondary screening for pancreatic cancer 1

• Implement pancreatic cancer surveillance in hereditary pancreatitis:

  • Start at age 40 or 10 years earlier than youngest affected relative
  • Annual imaging with MRI/MRCP and Endoscopic Ultrasound 1

Common Pitfalls to Avoid

1. Overaggressive fluid resuscitation in severe pancreatitis can worsen outcomes 4
2. Delaying enteral nutrition beyond 72 hours increases complications 1
3. Using normal saline instead of Lactated Ringer's solution leads to increased inflammation 3
4. Prophylactic antibiotics for sterile necrosis can lead to resistant organisms 1
5. Delaying ERCP beyond 24 hours in patients with cholangitis or severe gallstone pancreatitis 1