What is the management of acute pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis should follow a stepped approach including moderate fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, appropriate pain management, and targeted interventions for complications. 1, 2

Initial Assessment and Resuscitation

Fluid Management

• Moderate fluid resuscitation is recommended over aggressive hydration 1
  • Initial bolus of 10 ml/kg for hypovolemia, followed by 1.5 ml/kg/hour of Ringer's lactate
  • Adjust based on clinical and laboratory parameters
  • Lactated Ringer's solution is preferred over normal saline as it reduces systemic inflammation
  • Frequent reassessment of hemodynamic status to avoid fluid overload

Monitoring

• Continuous monitoring of vital signs in intermediate care units if organ dysfunction occurs
• ICU admission if dysfunction persists despite adequate fluid resuscitation
• Monitor for markers of severity: elevated hematocrit, blood urea nitrogen, or creatinine 3

Nutritional Support

• Early enteral nutrition should be initiated within 24-72 hours 1
  • Can be delivered via nasogastric or nasojejunal tube
  • Oral feeding can be resumed in mild pancreatitis once pain, nausea, and vomiting resolve 4
  • Diet should be rich in carbohydrates and proteins but low in fats (approximately 60g protein/day)
  • Avoid total parenteral nutrition when possible

Pain Management

• Implement a multimodal approach to analgesia 1, 5
  • Morphine or Dilaudid as first-line opioids
  • Consider epidural analgesia for severe cases to reduce opiate-related side effects
  • Coeliac plexus block (CPB) via EUS guidance for persistent pain unresponsive to conventional analgesia

Management of Biliary Pancreatitis

• Perform laparoscopic cholecystectomy with operative cholangiography during the same hospital admission for mild gallstone pancreatitis 1
• Early endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours is indicated for biliary pancreatitis with concurrent cholangitis 4, 2
• ERCP is not indicated in patients without cholangitis 2

Management of Complications

Pancreatic Necrosis

• Infected necrosis should be managed with a stepped approach 1
  • Start with percutaneous drainage
  • Many patients can be treated with antibiotics alone 5
  • Delay drainage as much as possible to reduce the number of procedures needed

Antibiotic Use

• Broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms when indicated
• Routine prophylactic antibiotics are generally not recommended 2
• Consider procalcitonin-based algorithm to distinguish inflammation from infection 2, 5

Other Complications

• For biliary obstruction: endoscopic placement of fully covered, self-expandable metallic biliary stent
• For duodenal obstruction: endoscopic placement of expandable metal stent instead of surgery

Follow-up and Prevention

• Regular follow-up every 6-12 months to evaluate:
  • Pain control
  • Nutritional status
  • Development of complications
  • Quality of life
• Provide brief alcohol intervention during hospital admission
• Monitor for refeeding syndrome in malnourished alcoholic patients
• For hereditary pancreatitis: refer to specialist centers for genetic counseling and secondary screening for pancreatic cancer

Special Considerations

• Early referral to specialist centers is crucial for patients with severe pancreatitis or complications 1
• Pancreatic resections should be performed only at specialty centers
• For high-risk individuals (genetic predisposition, hereditary pancreatitis), more intensive surveillance may be needed

Common Pitfalls to Avoid

1. Aggressive fluid resuscitation - increases mortality risk in severe pancreatitis and fluid-related complications 1
2. Delayed nutritional support - early enteral feeding is now standard of care
3. Overuse of antibiotics - should be targeted rather than prophylactic in most cases
4. Delayed cholecystectomy in gallstone pancreatitis - should be performed during index admission for mild cases
5. Premature invasive interventions - delay drainage of pancreatic necrosis when possible

The management approach has evolved from aggressive interventions to more targeted, less invasive strategies that improve outcomes while minimizing complications 5.