What is the treatment for pancreatitis?

Treatment of Acute Pancreatitis

The treatment of acute pancreatitis should focus on moderate fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, and etiology-specific interventions, while avoiding prophylactic antibiotics in the absence of infection. 1

Initial Management

Fluid Therapy

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution 2, 1
  • Recommended approach: 10 ml/kg bolus followed by 1.5 ml/kg/hr 3
  • Avoid aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/hr) as it increases risk of fluid overload and mortality without improving clinical outcomes 3, 4
• Monitor response to fluid therapy with serial measurements of hematocrit, BUN, and creatinine 1

Nutritional Support

• Initiate oral feeding early rather than keeping patients NPO 2, 1
• Begin enteral nutrition within 24-72 hours of admission 1
• Target nutritional intake: 25-35 kcal/kg/day and 1.2-1.5 g/kg/day protein 1
• For patients intolerant of oral feeding:
  • Use enteral nutrition via nasogastric (NG) or nasoenteral tube 2, 1
  • Nasojejunal tube feeding with elemental or semi-elemental formula is recommended 1
  • Reserve total parenteral nutrition (TPN) only for patients unable to tolerate enteral nutrition 1

Etiology-Specific Management

Biliary Pancreatitis

• Perform ultrasound within 24 hours to confirm biliary etiology 1
• No ERCP in the absence of cholangitis 2
• Cholecystectomy during initial admission for mild pancreatitis 2, 1
• For severe pancreatitis, delay cholecystectomy until resolution of lung injury and systemic disturbance 1

Alcoholic Pancreatitis

• Perform alcohol counseling during initial admission 2

Management of Complications

Infection Management

• Do not use prophylactic antibiotics 2
• For patients with >30% pancreatic necrosis or suspected sepsis:
  • Perform image-guided fine needle aspiration (FNA) for culture 7-14 days after onset 1
  • If infected necrosis is confirmed, implement a step-up approach 1:
    1. Percutaneous catheter drainage
    2. Endoscopic drainage
    3. Minimally invasive surgical necrosectomy
    4. Open surgical necrosectomy as last resort

Monitoring and Severity Assessment

• All patients with severe acute pancreatitis should be managed in a high dependency or intensive care unit 1
• Perform severity stratification within 48 hours of diagnosis using APACHE II score, clinical assessment, BMI, and presence of pleural effusion 1
• For severe cases, perform contrast-enhanced CT or MRI 72-96 hours after symptom onset 1

Common Pitfalls and Caveats

1. Fluid Management Pitfall: Recent high-quality evidence contradicts the traditional approach of aggressive fluid resuscitation. The 2022 WATERFALL trial in NEJM showed that aggressive fluid resuscitation resulted in higher rates of fluid overload (20.5% vs. 6.3%) without improving clinical outcomes 3. A 2024 meta-analysis further confirmed increased mortality with aggressive fluid resuscitation 4.

2. Antibiotic Use Caution: Avoid routine prophylactic antibiotics in the absence of confirmed infection, as this does not improve outcomes 2, 1.

3. Nutritional Support Timing: Delaying enteral nutrition beyond 72 hours can worsen outcomes. Early enteral nutrition helps maintain gut barrier function and reduce infectious complications 1.

4. ERCP Overuse: ERCP should not be performed routinely in biliary pancreatitis without evidence of cholangitis or persistent biliary obstruction 2, 1.

5. Referral Considerations: Patients with extensive necrotizing pancreatitis should be managed in, or referred to, a specialist unit 1.

Follow-up and Surveillance

• 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, surveillance for pancreatic cancer should begin at age 40 or 10 years earlier than the youngest affected relative 1