What is the step-by-step management of acute pancreatitis?

Step-by-Step Management of Acute Pancreatitis

The cornerstone of acute pancreatitis management includes early moderate fluid resuscitation with Lactated Ringer's solution, prompt pain control with opioids when needed, early enteral nutrition within 24-72 hours, and a step-up approach for managing complications. 1

Initial Assessment and Resuscitation (0-24 hours)

Fluid Resuscitation

• Begin with moderate fluid resuscitation using Lactated Ringer's solution rather than Normal Saline 1, 2
• Target moderate fluid resuscitation (10 mL/kg bolus if hypovolemic, followed by 1.5 mL/kg/hour) rather than aggressive resuscitation, as aggressive fluid therapy increases risk of fluid overload without improving outcomes 1, 3
• Reassess fluid status every 6-12 hours and adjust accordingly

Pain Management

• Start with non-opioid medications (acetaminophen) for mild pain 1
• Progress to opioids for moderate-severe pain, as they are recommended first-line for acute pancreatitis pain 1
• Consider patient-controlled analgesia (PCA) for severe cases 1
• Monitor for respiratory depression and sedation with opioid use 1

Diagnostic Workup

• Perform abdominal ultrasound within 24 hours to determine etiology (especially biliary) 1
• If diagnosis is uncertain, obtain contrast-enhanced CT 1
• Severity stratification should be completed within 48 hours using APACHE II score, clinical assessment, BMI, and presence of pleural effusion 1

Early Management (24-72 hours)

Nutrition

• 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 if oral intake not tolerated 1
• Reserve total parenteral nutrition only for patients unable to tolerate enteral nutrition 1

Imaging and Monitoring

• For severe cases, perform contrast-enhanced CT or MRI at 72-96 hours after symptom onset 1
• Use CT severity index for prognostication 1
• Continue to monitor vital signs, urine output, and laboratory parameters

Management of Complications

Infected Necrosis

• For patients with >30% pancreatic necrosis or clinical suspicion of sepsis, perform image-guided FNA for culture 7-14 days after onset 1
• Implement a 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 prophylactic antibiotics routinely in the absence of confirmed infection 4

Surgical Considerations

Biliary Pancreatitis

• For mild biliary pancreatitis, perform cholecystectomy within 2 weeks after discharge, preferably during the same admission 1
• For severe biliary pancreatitis, delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 1

Hemodynamic Instability

• 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

• Schedule regular follow-up every 6-12 months to evaluate pain control, nutritional status, complications, and quality of life 1
• For patients with hereditary pancreatitis, begin surveillance for pancreatic cancer at age 40 or 10 years earlier than the youngest affected relative 1
• Use annual imaging with both MRI/MRCP and Endoscopic Ultrasound (EUS) for surveillance 1

Important Caveats and Pitfalls

• Avoid aggressive fluid resuscitation: Recent evidence shows it increases risk of fluid overload without improving outcomes 1, 3
• Avoid routine prophylactic antibiotics: Use only in cases of confirmed infection or substantial necrosis 1, 4
• Avoid prolonged NPO status: Early enteral nutrition is beneficial and should be initiated within 24-72 hours 1, 4
• Avoid unnecessary ERCP: Only perform ERCP in the presence of concomitant cholangitis 4
• Recognize need for specialist referral: Patients with extensive necrotizing pancreatitis should be managed in or referred to a specialist unit 1