What is the treatment for acute pancreatitis in the hospital?

Treatment of Acute Pancreatitis in the Hospital Setting

The cornerstone of acute pancreatitis management in the hospital setting is moderate fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, and supportive care with appropriate monitoring in a high dependency or intensive care unit for severe cases. 1, 2

Initial Management and Fluid Resuscitation

• Fluid Therapy:

  • Moderate fluid resuscitation is preferred over aggressive fluid resuscitation
  • Use Lactated Ringer's solution at 1.5 ml/kg/hour, with a 10 ml/kg bolus only if hypovolemic 2
  • Aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) increases risk of fluid overload without improving outcomes 2
  • Lactated Ringer's solution is superior to Normal Saline in reducing systemic inflammatory response syndrome (SIRS) in the first 24 hours 3, 4

• Monitoring Requirements:

  • Serial hemoglobin/hematocrit measurements
  • Regular abdominal examinations for signs of increasing distension
  • Intra-abdominal pressure monitoring when indicated 1
  • Severity stratification within 48 hours using APACHE II score, clinical assessment, BMI, and presence of pleural effusion 1

Nutritional Support

• Begin enteral nutrition within 24-72 hours of admission 1
• Target nutritional intake: 25-35 kcal/kg/day, 1.2-1.5 g/kg/day protein 1
• Nasojejunal tube feeding with elemental or semi-elemental formula for patients unable to tolerate oral intake 1
• Reserve total parenteral nutrition only for patients unable to tolerate enteral nutrition 1

Management Based on Etiology

Gallstone Pancreatitis

• Urgent ERCP with sphincterotomy is indicated for:

  • Severe gallstone pancreatitis with no response to treatment within 48 hours
  • Presence of cholangitis
  • Jaundice or dilated common bile duct 5, 1
  • ERCP should be performed within 72 hours of pain onset 5

• Timing of Cholecystectomy:

  • For mild pancreatitis: Perform within 2 weeks after discharge, preferably during the same admission 5
  • For severe pancreatitis: Delay until signs of lung injury and systemic disturbance have resolved 5
  • For medically unfit patients: Endoscopic sphincterotomy alone is adequate 5, 1

Management of Pancreatic Necrosis

• For patients with >30% pancreatic necrosis or clinical suspicion of sepsis:

  • Perform image-guided fine needle aspiration (FNA) for culture 7-14 days after onset 5
  • Complete debridement of all cavities containing necrotic material is required for infected necrosis 5

• Step-up approach for infected necrosis:

  1. Percutaneous catheter drainage
  2. Endoscopic drainage
  3. Minimally invasive surgical necrosectomy
  4. Open surgical necrosectomy as last resort 1

Antibiotic Management

• Do not routinely administer antibiotics in mild cases
• Limit antibiotic prophylaxis to 14 days or less in cases of substantial pancreatic necrosis (>30% of gland) 1
• Confirm suspected infected necrosis by CT-guided FNA for culture before starting antibiotics 1

Specialized Care Considerations

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit 5
• Transfer to a specialized center with ICU capabilities for severe cases 1
• Hemodynamically unstable patients may require surgical intervention with necrosectomy and drainage 1

Important Caveats and Pitfalls

• Avoid aggressive fluid resuscitation as it increases risk of fluid overload (20.5% vs 6.3%) without improving outcomes 2
• Early CT scan (<72 hours) will not accurately show necrotic areas and will not modify clinical management during the first week 1
• Delay cholecystectomy in severe cases until inflammation resolves to reduce surgical complications 5
• Avoid routine use of prophylactic antibiotics in the absence of confirmed infection 1

The most recent high-quality evidence from the WATERFALL trial (2022) demonstrates that moderate fluid resuscitation is safer than aggressive resuscitation, challenging previous dogma about early aggressive hydration in acute pancreatitis 2.