What is the classification and treatment of pancreatitis?

Pancreatitis Classification and Treatment

Acute pancreatitis should be classified according to the Revised Atlanta Classification (2012) into mild, moderately severe, severe, and critical categories, with treatment tailored to severity level and managed in specialized units for severe cases. 1, 2, 3

Classification of Pancreatitis

Acute Pancreatitis Classification

The Revised Atlanta Classification (2012) divides acute pancreatitis into:

1. Mild Acute Pancreatitis

   • No organ failure
   • No local or systemic complications
   • Low mortality rate
   • Usually resolves within the first week 2, 3

2. Moderately Severe Acute Pancreatitis

   • Transient organ failure (<48 hours)
   • Local complications or exacerbation of comorbid disease
   • Moderate mortality rate 2, 3

3. Severe Acute Pancreatitis

   • Persistent organ failure (≥48 hours)
   • High mortality rate (13-35%) 1, 2, 3

4. Critical Acute Pancreatitis

   • Persistent organ failure AND infected (peri)pancreatic necrosis
   • Highest mortality rate (up to 35.2%) 1, 4

Morphological Classification

Acute pancreatitis can be morphologically classified as:

• Interstitial Edematous Pancreatitis: Pancreatic inflammation without necrosis
• Necrotizing Pancreatitis: Involving necrosis of:
  • Pancreatic parenchyma and peripancreatic tissues (most common)
  • Pancreatic parenchyma alone (least common)
  • Peripancreatic tissues only (~20% of cases) 2, 3

Local Complications

Local complications are classified as:

1. Acute Peripancreatic Fluid Collections: Early collections without a wall
2. Pseudocyst: Encapsulated fluid collection (rare in acute pancreatitis)
3. Acute Necrotic Collection: Collection containing variable amounts of fluid and necrotic material
4. Walled-off Necrosis: Mature, encapsulated collection of pancreatic/peripancreatic necrosis 2, 3, 5

Treatment of Pancreatitis

General Management Principles

1. Diagnosis and Severity Assessment

   • Correct diagnosis should be made within 48 hours of admission
   • Severity stratification should be completed within 48 hours 6

2. Treatment Setting

   • Mild cases: Regular ward management
   • Severe cases: All cases of severe acute pancreatitis should be managed initially in an HDU or ITU setting with full systems support 6
   • Consider referral to a specialist unit for extensive necrotizing pancreatitis or other complications requiring intensive care 6

Specific Management Based on Severity

Mild Acute Pancreatitis

• Enteral nutrition is unnecessary if the patient can consume normal food after 5-7 days
• Oral feeding can be progressively attempted once pain resolves 6
• If oral feeding is not possible due to persistent pain for more than 5 days, consider tube feeding 6

Moderately Severe to Severe Pancreatitis

• Enteral nutrition is indicated whenever possible
• Continuous enteral nutrition is recommended for all patients who tolerate it
• Enteral nutrition should be supplemented by parenteral nutrition if needed 6
• Try jejunal route if gastric feeding is not tolerated 6

Imaging and Interventions

1. Imaging Protocol

   • Ultrasonography at admission to determine etiology (especially biliary)
   • Dynamic CT scanning should be performed on all patients with severe acute pancreatitis between 3-10 days of admission 6, 1
   • MRCP should be considered to detect occult stones in patients with unknown etiology 1

2. Interventional Procedures

   • ERCP facilities should be available for common bile duct evaluation followed by sphincterotomy and stone extraction as required, particularly in severe gallstone pancreatitis 6
   • Radiological facilities should be available for percutaneous guided aspiration and drainage techniques 6

3. Gallstone Management

   • Patients with mild gallstone pancreatitis should have definitive management of gallstones ideally within two weeks and no longer than four weeks 6

Special Considerations

• Infected Necrosis: Patients with moderately severe pancreatitis who develop infected necrosis may have outcomes similar to those with severe pancreatitis 7
• Early Organ Failure: Patients with organ failure within seven days of disease onset may represent a subgroup with higher mortality 7
• Nutrition Route: In case of gastric outlet obstruction, the feeding tube tip should be placed distal to the obstruction; if impossible, parenteral nutrition should be given 6

By following this classification-guided approach to treatment, mortality should be lower than 10% overall and less than 30% in severe groups 6.