What is the treatment for acute on chronic pancreatitis?

Treatment for Acute on Chronic Pancreatitis

The treatment for acute on chronic pancreatitis requires aggressive fluid resuscitation, early enteral nutrition, pain management, and targeted interventions for complications, with surgical intervention providing superior long-term pain relief compared to endoscopic therapy for patients with gallstones and intraductal dilation. 1

Initial Management (First 72 Hours)

Fluid Resuscitation

• Adequate fluid resuscitation is cornerstone therapy
• Lactated Ringer's solution is preferred over normal saline
• Goal-directed, moderate hydration rather than aggressive hydration 1, 2
• Monitor hemodynamic stability and consider ICU admission for unstable patients 1

Diagnostic Confirmation

• Perform ultrasound within 24 hours to evaluate for gallstones 1
• Dynamic CT scan with non-ionic contrast within 3-10 days to assess necrosis or fluid collections 1
• Consider MRI or Endoscopic Ultrasound (EUS) if tumor suspicion exists 1
• Severity stratification within 48 hours using APACHE II score, clinical assessment, BMI, and presence of pleural effusion 1

Pain Management

• Multimodal approach to minimize opioid requirements 3
• Consider celiac plexus block for debilitating pain when other measures fail (case-by-case basis) 1

Nutritional Support

• Early enteral nutrition (within 24-72 hours) is preferred over parenteral nutrition 1, 2
• Recommended intake: 25-35 kcal/kg/day, 1.2-1.5 g/kg/day protein, 3-6 g/kg/day carbohydrates 1
• Normal "on-demand" diet has positive effect on recovery and hospital stay length 3
• Nasojejunal tube feeding with elemental or semi-elemental formula for those unable to tolerate oral intake 1
• Total parenteral nutrition only if enteral nutrition cannot be tolerated 1

Management of Complications

Infection Management

• Do not routinely administer antibiotics in mild cases 1
• Limit antibiotic prophylaxis to 14 days or less in substantial pancreatic necrosis (>30% of gland) 1
• Confirm suspected infected necrosis by CT-guided fine-needle aspiration for culture 1
• Procalcitonin-based algorithm may help distinguish inflammation from infection 2

Intervention for Gallstone Pancreatitis

• ERCP with stent insertion is preferred treatment for biliary obstruction 1
• Fully covered self-expanding metal stents (FCSEMS) favored over multiple plastic stents when feasible 1
• Urgent ERCP (within 24 hours) for patients with gallstone pancreatitis and cholangitis, but not indicated without cholangitis 2

Management of Pancreatic Necrosis

• Step-up approach for infected necrosis: 1
  1. Percutaneous catheter drainage
  2. Endoscopic drainage
  3. Minimally invasive surgical necrosectomy
  4. Open surgical necrosectomy as last resort
• Delay drainage as much as possible (associated with fewer procedures) 3
• Consider lumen-apposing metal stent for transgastric drainage and necrosectomy when needed 3

Definitive Treatment for Chronic Component

Endoscopic Therapy

• ERCP with conventional stone extraction for small stones (high success rates) 1
• Extracorporeal shock wave lithotripsy (ESWL) for stone fragmentation (>90% effective) 1
• Pancreatoscopy-directed lithotripsy for complex stones (88% technical success) 1
• ERCP with stent placement can relieve pain in up to 85% of patients (requires 6-12 months of stent therapy) 1

Surgical Intervention

• Surgical intervention provides superior long-term pain relief compared to endoscopic therapy 1
• ESCAPE trial showed higher complete/partial pain relief with surgery (58% vs 39%) 1
• Surgery is a one-time intervention versus multiple endoscopic procedures 1
• Preferred for patients with gallstones and intraductal dilation 1
• Consider patient's surgical candidacy and preference 1

Monitoring and Follow-up

• ICU admission for hemodynamically unstable patients 1
• Serial hemoglobin/hematocrit measurements 1
• Regular abdominal examination for signs of increasing distension 1
• Monitor intra-abdominal pressure when indicated 1
• Follow-up every 6-12 months to evaluate:
  • Pain control
  • Nutritional status
  • Development of complications
  • Quality of life 1

Convalescent Treatment and Prevention

• Brief alcohol intervention during admission (reduces 30-day readmission by half) 1
• Cholecystectomy for gallstone pancreatitis 2
• Lipid-lowering medications for hypertriglyceridemia-induced acute pancreatitis 2

Common Pitfalls and Caveats

• Avoid aggressive fluid resuscitation, which may worsen outcomes 2, 3
• Do not delay enteral nutrition unnecessarily 1, 2
• Avoid routine use of prophylactic antibiotics in mild cases or without confirmed infection 1
• Recognize that contrast-enhanced CT carries risk of extending necrosis and exacerbating renal impairment 1
• ESWL for pancreaticolithiasis is not widely available in the United States 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis 1