What is the management of pancreatitis?

Management of Acute Pancreatitis

Moderate fluid resuscitation with Lactated Ringer's solution is the cornerstone of early management for acute pancreatitis, avoiding aggressive fluid resuscitation which increases the risk of fluid overload without improving clinical outcomes. 1, 2

Diagnosis and Initial Assessment

• Diagnosis requires at least 2 of 3 criteria:

  • Abdominal pain consistent with pancreatitis
  • Serum lipase and/or amylase >3 times upper limit of normal
  • Characteristic findings on abdominal imaging 1

• Severity stratification within 48 hours using:

  • Revised Atlanta Classification (mild, moderately severe, severe)
  • APACHE II score
  • Clinical assessment
  • BMI
  • Presence of pleural effusion on chest radiograph 1

Initial Management

Fluid Resuscitation

• Use moderate fluid resuscitation with Lactated Ringer's solution:

  • For hypovolemic patients: 10 ml/kg bolus followed by 1.5 ml/kg/hour
  • For normovolemic patients: No bolus, start with 1.5 ml/kg/hour 2
  • Adjust based on clinical status at 12,24,48, and 72 hours

• Lactated Ringer's solution is superior to Normal Saline:

  • Reduces systemic inflammatory response syndrome (SIRS) at 24 hours 3
  • Lowers C-reactive protein levels 3

• Avoid aggressive fluid resuscitation as recent evidence shows it increases fluid overload (20.5% vs 6.3%) without improving outcomes 2

Imaging

• Transabdominal ultrasound within 24 hours to determine etiology
• Contrast-enhanced CT or MRI indicated:
  • When diagnosis is uncertain
  • In severe cases (72-96 hours after symptom onset)
  • When complications are suspected 1

Nutritional Support

• Early enteral nutrition within 24-72 hours of admission:

  • Target: 25-35 kcal/kg/day and 1.2-1.5 g/kg/day protein
  • Nasojejunal tube feeding with elemental or semi-elemental formula for patients unable to tolerate oral intake 1

• Avoid total parenteral nutrition as it increases complications 4

Pain Management

• Begin with oral non-opioid medications (e.g., acetaminophen)
• Progress to oral opioids if inadequate pain control
• For severe pain:
  • Patient-controlled analgesia with opioid-based PCA
  • Consider ICU monitoring for high-dose opioid requirements
  • Consider adjuvant medications (gabapentin, pregabalin, duloxetine) for neuropathic pain components 1

Antibiotic Management

• Do not use prophylactic antibiotics routinely
• Consider antibiotics only for:
  • Infected necrosis (confirmed by image-guided FNA)
  • Cholangitis
  • Other extrapancreatic infections
  • Limit to 14 days or less in cases of substantial pancreatic necrosis (>30% of gland) 1, 4

Management of Complications

Infected Necrosis

• Implement step-up approach:

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

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

  • Perform image-guided FNA for culture 7-14 days after onset 1

Biliary Pancreatitis

• Cholecystectomy timing:

  • Mild pancreatitis: within 2 weeks after discharge
  • Severe pancreatitis: delay until resolution of lung injury and systemic disturbance 1

• Avoid ERCP in the absence of concomitant cholangitis 4

Special Considerations

• Severe acute pancreatitis patients should be admitted to ICU
• Refer patients with extensive necrotizing pancreatitis to specialist units 1
• Regular follow-up every 6-12 months to evaluate:
  • Pain control
  • Nutritional status
  • Development of complications
  • Quality of life 1

Prognosis and Outcomes

• Overall mortality should be lower than 10%
• Mortality in severe pancreatitis should be less than 30% 1
• Increasing recognition of risks after acute pancreatitis:
  • Recurrence
  • Progression to chronic pancreatitis
  • Development of diabetes
  • Exocrine pancreatic insufficiency 4