What is the management of acute pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires early aggressive fluid resuscitation with Lactated Ringer's solution, early enteral nutrition within 24-72 hours, multimodal analgesia, and a stepped approach to complications including infected necrosis. 1

Initial Assessment and Classification

• Classify severity as mild (80% of cases, <5% mortality) or severe (20% of cases, 95% mortality) using objective criteria 1
• Identify etiology in 75-80% of cases (common causes: gallstones, alcohol, hypertriglyceridemia, medications, post-ERCP) 1
• Obtain ultrasound examination of the gallbladder within 24 hours of diagnosis 1
• Consider dynamic CT scan with non-ionic contrast within 3-10 days to assess for necrosis or peripancreatic fluid collections 1

Fluid Resuscitation

• Implement moderate fluid resuscitation with Lactated Ringer's solution (preferred over normal saline) 1
• Use goal-directed therapy for fluid management, titrating IV fluids to specific targets:
  • Heart rate
  • Mean arterial pressure
  • Central venous pressure
  • Urine output
  • Blood urea nitrogen concentration
  • Hematocrit 1
• Early aggressive hydration has been shown to hasten clinical improvement in mild acute pancreatitis 2

Nutritional Support

• Initiate early enteral nutrition within 24-72 hours for patients with severe acute pancreatitis 1
• Enteral nutrition is strongly preferred over parenteral nutrition as it reduces mortality, infections, and organ failure 1
• Recommended nutritional parameters:
  • Energy: 25-35 kcal/kg body weight/day
  • Protein: 1.2-1.5 g/kg body weight/day (approximately 60g/day)
  • Carbohydrates: 3-6 g/kg body weight/day
  • Lipids: up to 2 g/kg body weight/day 1
• Diet should be rich in carbohydrates and proteins but low in fats 1
• For mild pancreatitis, oral feeding can resume once pain, nausea, and vomiting have resolved 3

Pain Management

• Implement a multimodal approach to analgesia:
  • First-line: Morphine or Dilaudid
  • Consider epidural analgesia for severe cases 1
  • For persistent pain unresponsive to conventional analgesia, consider coeliac plexus block (CPB) via EUS guidance 1

Management of Biliary Pancreatitis

• Urgent ERCP with sphincterotomy is indicated in patients with:
  • Cholangitis
  • Persistent biliary obstruction
  • Failure to improve within 48 hours despite intensive resuscitation 1
• Always perform ERCP under antibiotic cover 1
• For mild biliary pancreatitis, perform laparoscopic cholecystectomy during the same hospital admission 1, 3
• For severe biliary pancreatitis, perform cholecystectomy after clinical improvement 1

Management of Complications

Infected Necrosis

• Use a stepped approach starting with percutaneous drainage 1
• Surgical intervention for infected necrosis should be postponed as late as possible, preferably beyond 4 weeks after disease onset 4
• When required, debride all cavities containing necrotic material 1

Antibiotic Use

• Prophylactic antibiotics are not supported by evidence in mild cases 1
• When indicated (infected necrosis), use broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms 1

Intra-abdominal Hypertension and Compartment Syndrome

• Monitor intra-abdominal pressure, especially during aggressive fluid resuscitation 4
• Use conservative measures first for abdominal compartment syndrome
• Consider surgical decompression if conservative management fails 4

ICU/HDU Management for Severe Cases

• Transfer severe cases to ICU/HDU setting 1
• Implement multidisciplinary approach including:
  • Peripheral venous access
  • Central venous line
  • Urinary catheter
  • Nasogastric tube 1
• Monitor vital signs, oxygen saturation, urine output, and temperature hourly 1
• Consider Swan-Ganz catheter placement if cardiocirculatory compromise exists 1
• Perform regular arterial blood gas analysis to detect hypoxia and acidosis 1

Follow-up and Prevention of Recurrence

• 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 admission (reduces 30-day readmission by 50%) 1
• For hereditary pancreatitis, implement surveillance for pancreatic cancer starting at age 40 or 10 years earlier than the youngest affected relative 1
  • Annual imaging using both MRI/MRCP and Endoscopic Ultrasound (EUS)

Common Pitfalls to Avoid

• Delaying enteral nutrition in favor of parenteral nutrition
• Using prophylactic antibiotics in mild cases without evidence of infection
• Performing early surgery for infected pancreatic necrosis (within first two weeks)
• Neglecting to identify and address the underlying etiology
• Failing to monitor for and manage intra-abdominal hypertension during fluid resuscitation

The management approach has evolved from the older strategies of aggressive hydration with normal saline to more goal-directed, moderate fluid resuscitation with Lactated Ringer's solution 5. Recent evidence continues to support early enteral nutrition and a stepped approach to managing complications.