Treatment of Acute Pancreatitis
The optimal management of acute pancreatitis requires aggressive fluid resuscitation with Lactated Ringer's solution, early enteral nutrition within 24-72 hours, multimodal pain management, and targeted interventions based on disease severity and etiology. 1
Initial Assessment and Classification
- Classify severity using established scoring systems (Revised Atlanta Classification or Determinant-based Classification)
- All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 2
Fluid Resuscitation
- Lactated Ringer's solution is preferred over normal saline as it reduces systemic inflammation 1
- Initial approach:
- Initial bolus of 10 ml/kg in case of hypovolemia
- Follow with 1.5 ml/kg/hour of Lactated Ringer's solution
- Adjust according to clinical and laboratory parameters 1
- Monitor fluid status every 6-8 hours to prevent fluid overload
- Warning signs of fluid overload include:
- Rapid weight gain
- Incident ascites
- Jugular vein engorgement
- Abdominal compartment syndrome
- Pulmonary/peripheral edema 1
Caution: Recent evidence from the WATERFALL trial suggests that aggressive fluid resuscitation may lead to higher rates of fluid overload without improving clinical outcomes compared to moderate fluid resuscitation 3. This represents a shift from previous practice patterns that favored more aggressive approaches.
Nutritional Support
- Early enteral nutrition should be initiated within 24-72 hours via nasogastric or nasojejunal tube 1
- Diet recommendations:
- For mild pancreatitis: Diet rich in carbohydrates, moderate in protein, and moderate in fat
- For severe pancreatitis: Diet rich in carbohydrates and proteins but low in fats, with approximately 60 grams of protein per day 1
- Enteral route is strongly preferred over parenteral nutrition 1
Pain Management
- Implement a multimodal approach to analgesia:
- First-line: Morphine or Dilaudid
- For severe cases: Consider epidural analgesia
- For persistent pain unresponsive to conventional analgesia: Consider coeliac plexus block (CPB) via EUS guidance 1
Biliary Pancreatitis Management
- Urgent therapeutic ERCP should be performed within the first 72 hours after pain onset in patients with:
- Suspected or proven gallstone etiology with predicted or actual severe pancreatitis
- Cholangitis
- Jaundice
- Dilated common bile duct 2
- All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 2
Timing of Cholecystectomy
- For mild gallstone pancreatitis: Perform cholecystectomy during the same admission or within two weeks after discharge 2
- For severe gallstone pancreatitis: Delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 2
Management of Pancreatic Necrosis
- All patients with persistent symptoms and >30% pancreatic necrosis, or smaller areas of necrosis with clinical suspicion of sepsis, should undergo image-guided FNA for culture 7-14 days after onset 2
- For infected necrosis: Complete debridement of all cavities containing necrotic material is required 2
- Consider a stepped approach starting with percutaneous drainage before surgical intervention 1
Imaging
- Initial ultrasound to determine etiology, especially biliary causes
- Contrast-enhanced CT is optimal 72-96 hours after symptom onset to assess severity and detect complications 1
Follow-up and Surveillance
- Regular follow-up every 6-12 months to evaluate:
- Pain control
- Nutritional status
- Development of complications
- Quality of life 1
Common Pitfalls to Avoid
- Inadequate fluid resuscitation increases risk of pancreatic necrosis and organ failure
- Overly aggressive fluid resuscitation can lead to fluid overload complications 3
- Delayed nutritional support can worsen outcomes
- Failure to identify and address biliary obstruction in gallstone pancreatitis
- Premature cholecystectomy in severe cases before resolution of inflammatory response