What is the management of acute pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis should follow a step-up approach with early fluid resuscitation using Lactated Ringer's solution, prompt pain control with opioids if needed, early enteral nutrition within 24-72 hours, and targeted interventions for complications. 1

Initial Assessment and Resuscitation (First 72 Hours)

Fluid Resuscitation

• Use moderate fluid resuscitation with Lactated Ringer's solution rather than normal saline 1, 2
  • Lactated Ringer's solution reduces severity by 31%, mortality by 62%, and systemic and local complications 2
  • Avoid aggressive fluid resuscitation as it increases risk of fluid overload without improving outcomes 1, 3
• Target moderate hydration with goal-directed therapy 1
• Monitor for signs of fluid overload, especially in patients with cardiac or renal comorbidities

Pain Management

• Begin with opioids as first-line treatment for acute pancreatitis pain 1
  • Opioids decrease need for supplementary analgesia without increasing complications
  • Consider patient-controlled analgesia (PCA) for severe cases
• Monitor for respiratory depression, sedation, and signs of dependence 1
• Consider adjuvant medications (gabapentin, pregabalin, duloxetine) for neuropathic pain components 1

Nutritional Support

• Start 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
• Use 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

Diagnostic Workup

• Perform ultrasound within 24 hours to determine etiology (especially biliary) 1
• When diagnosis is uncertain, obtain CT for definitive evidence 1
• Perform contrast-enhanced CT or MRI in severe cases 72-96 hours after symptom onset 1
• Stratify severity within 48 hours using:
  • APACHE II score
  • Clinical assessment
  • Body mass index
  • Presence of pleural effusion on chest radiograph 1
• Use CT severity index for prognostication 1

Management of Complications

Pancreatic Necrosis

• For patients with >30% pancreatic necrosis or clinical suspicion of sepsis:
  • Perform image-guided fine needle aspiration for culture 7-14 days after onset 1
  • Implement step-up approach for infected necrosis: 1
    1. Percutaneous catheter drainage
    2. Endoscopic drainage
    3. Minimally invasive surgical necrosectomy
    4. Open surgical necrosectomy (last resort)

Antibiotic Use

• Limit antibiotic prophylaxis to 14 days or less in cases of substantial pancreatic necrosis (>30% of gland) 1
• Do not use routine prophylactic antibiotics in the absence of documented infection 4, 5

Biliary Pancreatitis Management

• For mild pancreatitis: perform cholecystectomy within 2 weeks after discharge, preferably during the same admission 1
• For severe pancreatitis: delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 1
• Perform urgent ERCP (within 24 hours) for patients with gallstone pancreatitis and cholangitis 4

Special Considerations

Severe Cases

• Consider management in or referral to a specialist unit for patients with extensive necrotizing pancreatitis 1
• Monitor for organ failure and provide appropriate support
• ICU monitoring for patients with severe pain requiring high-dose opioids 1
• Consider specialist pain service consultation for difficult-to-control pain 1

Hemodynamically Unstable Patients

• May require surgical intervention with necrosectomy and drainage 1
• Consider damage control surgery with temporary abdominal closure in severe cases 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
• Surveillance for pancreatic cancer in patients with hereditary pancreatitis 1

Common Pitfalls to Avoid

• Aggressive fluid resuscitation can lead to fluid overload in 20.5% of patients versus 6.3% with moderate resuscitation 3
• Delaying enteral nutrition beyond 72 hours can worsen outcomes
• Using normal saline instead of Lactated Ringer's solution (LR reduces SIRS at 24 hours compared to normal saline) 6, 2
• Routine use of prophylactic antibiotics without evidence of infection
• Delaying cholecystectomy in mild gallstone pancreatitis
• Failing to recognize and manage pancreatic exocrine and endocrine insufficiency 5