What is the treatment for acute pancreatitis?

Treatment for Acute Pancreatitis

The cornerstone of acute pancreatitis management includes early goal-directed fluid resuscitation with Lactated Ringer's solution, early oral feeding within 24 hours as tolerated, multimodal pain management, and avoidance of prophylactic antibiotics in the absence of confirmed infection. 1

Initial Assessment and Severity Stratification

• Perform severity stratification within 48 hours of diagnosis using:

  • APACHE II score
  • CT severity index (score ≥4 indicates severe disease)
  • Presence of organ failure
  • BISAP score 1

• Determine etiology with appropriate testing:

  • Early ultrasound scanning within 24 hours for gallstones
  • Measure blood lipid and calcium concentrations if etiology remains unclear
  • Consider CT scan to exclude pancreatic tumor, particularly in elderly patients 1

Fluid Resuscitation

• Use goal-directed therapy with Lactated Ringer's solution rather than normal saline:

  • Initial bolus of 20 ml/kg followed by 3 ml/kg/h for aggressive hydration in mild cases 2
  • Titrate to specific clinical targets: heart rate, mean arterial pressure, central venous pressure, urine output, BUN, and hematocrit 1, 3

• Avoid over-resuscitation as excessive fluid can worsen abdominal compartment syndrome and respiratory function 1

• Early aggressive hydration with Lactated Ringer's solution has been shown to hasten clinical improvement in mild acute pancreatitis (70% vs. 42% improvement at 36 hours compared to standard hydration) 2

Nutritional Support

• Initiate oral feeding early (within first 24 hours) as tolerated:

  • Early feeding reduces risk of interventions for necrosis by 2.5 times (OR 2.47; 95% CI 1.41-4.35) 1
  • Do not keep patients fasting unnecessarily

• For more severe cases, provide early enteral nutrition (within 24-72 hours):

  • Preferred over parenteral nutrition
  • Target 25-35 kcal/kg/day
  • Protein: 1.2-1.5 g/kg/day
  • Carbohydrates: 3-6 g/kg/day
  • Lipids: up to 2 g/kg/day 1

Pain Management

• Implement multimodal analgesia approach:
  • Morphine or hydromorphone as first-line opioids
  • Consider epidural analgesia for severe cases
  • For persistent pain unresponsive to conventional analgesia, consider celiac plexus block via EUS guidance 1

Antibiotic Use

• Do not administer antibiotics routinely in mild cases or prophylactically in severe/necrotizing pancreatitis 1

• Reserve broad-spectrum antibiotics only for:

  • Confirmed infected necrosis
  • Specific infections (chest, urine, bile, or cannula-related)
  • Coverage should include gram-negative, gram-positive, and anaerobic organisms 1

Management of Gallstone Pancreatitis

• Perform early ultrasound scanning within 24 hours
• Consider dynamic CT scan with non-ionic contrast within 3-10 days to assess for necrosis or peripancreatic fluid collections
• ERCP is indicated in the presence of:
  • Jaundice
  • Dilated common bile duct
  • Recurrent attacks
  • Urgent ERCP (within 24 hours) for patients with gallstone pancreatitis and cholangitis 1, 4

Monitoring Requirements

• Mild cases:

  • Basic monitoring of temperature, pulse, blood pressure, and urine output on a general ward

• Severe cases:

  • Transfer to ICU/HDU
  • Hourly monitoring of vital signs, oxygen saturation, urine output, and temperature
  • Peripheral venous access, central venous line, urinary catheter, and nasogastric tube 1

Management of Complications

• Infected necrosis or symptomatic collections:
  • Follow step-up approach:
    1. Percutaneous catheter drainage
    2. Endoscopic drainage
    3. Minimally invasive surgical necrosectomy
    4. Open surgical necrosectomy (last resort)
  • Avoid draining asymptomatic collections as unnecessary drainage increases infection risk 1

Convalescent Care and Prevention of Recurrence

• Provide brief alcohol intervention during admission:

  • Patients receiving alcohol counseling were half as likely to be readmitted within 30 days 1

• Regular follow-up every 6-12 months to evaluate:

  • Pain control
  • Nutritional status
  • Development of complications
  • Quality of life 1

• For patients with hereditary pancreatitis, implement surveillance for pancreatic cancer:

  • 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 cases, which may be futile and potentially harmful 3
2. Unnecessary use of prophylactic antibiotics in the absence of confirmed infection 1
3. Prolonged fasting and delayed enteral nutrition 1
4. Routine CT scanning in mild cases without clinical deterioration 1
5. Draining asymptomatic fluid collections, which increases infection risk 1

The management approach should aim for mortality rates of <10% overall and <30% in severe cases, with correct diagnosis established within 48 hours and etiology determined in at least 80% of cases 1.