What is the treatment for pancreatitis?

Treatment of Pancreatitis

The cornerstone treatment for pancreatitis includes early aggressive fluid resuscitation with Lactated Ringer's solution, pain management starting with non-opioid medications and progressing to opioids if needed, early enteral nutrition within 24-72 hours, and management of complications as they arise. 1

Initial Management

Fluid Resuscitation

• Use moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive fluid resuscitation or normal saline 1, 2, 3
• Goal-directed hydration is preferred over aggressive hydration 2
• Early aggressive fluid resuscitation is crucial in severe acute pancreatitis 4

Pain Management

• Begin with oral non-opioid medications (e.g., acetaminophen) 1
• Progress to oral opioids if inadequate pain control is achieved 1
• Consider patient-controlled analgesia (PCA) for severe cases 1
• Consider multimodal pain management including epidural analgesia to reduce opiate side effects 3
• For refractory pain, consider celiac plexus block for temporary relief 1

Nutritional Support

• 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
• Use nasojejunal tube feeding with elemental or semi-elemental formula for patients unable to tolerate oral intake 1
• A normal "on-demand" diet has positive effects on recovery and hospital stay length 3
• Total parenteral nutrition should only be used when enteral nutrition cannot be tolerated 1

Diagnosis and Monitoring

Initial Assessment

• Perform ultrasound within 24 hours to determine etiology (especially biliary) 1
• When diagnosis is uncertain, CT provides definitive evidence 1
• Perform contrast-enhanced CT or MRI in severe cases 72-96 hours after symptom onset 1

Severity Stratification

• Complete within 48 hours of diagnosis 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

Infected 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 a 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
• Delay drainage as much as possible to reduce the number of procedures 3
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone 3

Antibiotic Use

• Limit antibiotic prophylaxis to 14 days or less in cases of substantial pancreatic necrosis (>30% of gland) 1
• Routine use of prophylactic antibiotics is generally not recommended 2
• Consider procalcitonin-based algorithm to distinguish between inflammation and infection 2, 3

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
• Urgent ERCP (within 24 hours) should be performed for patients with gallstone pancreatitis and cholangitis, but is not indicated in patients without cholangitis 2

Special Considerations

Severe Acute Pancreatitis

• Provide intensive care with close monitoring and support of organ function 4
• Early supportive treatment of organ failure is essential 4
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis 1
• Hemodynamically unstable patients may require surgical intervention with necrosectomy and drainage 1

Follow-up and Prevention

• 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
• Address underlying causes to prevent recurrence:
  • Cholecystectomy in gallstone pancreatitis
  • Lipid-lowering medications in hypertriglyceridemia-induced pancreatitis
  • Alcohol intervention in alcoholic pancreatitis 2

Common Pitfalls and Caveats

• Avoid aggressive fluid resuscitation as it increases risk of fluid overload without improving outcomes 1, 3
• Do not delay enteral nutrition unnecessarily as early feeding improves outcomes 1, 2
• Avoid routine use of prophylactic antibiotics in all cases of pancreatitis 2
• Monitor patients on opioids for respiratory depression, sedation, and signs of dependence 1
• Do not delay referral to specialist centers for patients with extensive necrotizing pancreatitis 1