What is the management of pancreatitis?

Management of Acute Pancreatitis

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

Diagnosis and 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, or severe)
  • APACHE II score
  • Clinical assessment
  • BMI
  • Presence of pleural effusion on chest radiograph 1

Initial Management

Fluid Resuscitation

• Use Lactated Ringer's solution rather than normal saline
  • LRS significantly reduces systemic inflammation (84% reduction in SIRS at 24h) 3
  • Moderate resuscitation protocol:
    • 10 ml/kg bolus if hypovolemic (no bolus if normovolemic)
    • Followed by 1.5 ml/kg/hour maintenance 2
  • Avoid aggressive fluid resuscitation which causes fluid overload (20.5% vs 6.3%) without improving outcomes 2

Nutrition

• Start early enteral nutrition within 24-72 hours of admission
  • Target: 25-35 kcal/kg/day and 1.2-1.5 g/kg/day protein
  • Use nasojejunal tube feeding with elemental or semi-elemental formula for patients unable to tolerate oral intake 1
  • Avoid total parenteral nutrition 4

Pain Management

• Start with oral non-opioid medications (e.g., acetaminophen)
• Progress to oral opioids if inadequate pain control
• Consider patient-controlled analgesia for severe cases
• Add adjuvant medications (gabapentin, pregabalin, duloxetine) for neuropathic pain components
• Monitor for respiratory depression, sedation, and signs of dependence 1

Imaging and Further Assessment

• 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
• Use CT severity index for prognostication 1

Management of Complications

Infected Necrosis

• Do not use prophylactic antibiotics routinely

• Consider antibiotics only for:

  • Confirmed infected necrosis
  • Cholangitis
  • Other extrapancreatic infections
  • Limit to 14 days or less in cases of substantial pancreatic necrosis (>30% of gland) 1

• For 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

Biliary Pancreatitis

• Avoid ERCP in the absence of concomitant cholangitis 4
• Perform cholecystectomy within 2 weeks after discharge for mild pancreatitis
• Delay cholecystectomy until resolution of lung injury and systemic disturbance for severe pancreatitis 1

Special Considerations

• Admit patients with severe acute pancreatitis to ICU whenever possible
• 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 Monitoring

• Overall mortality should be lower than 10%, and less than 30% in severe pancreatitis
• Monitor for progression to chronic pancreatitis, diabetes, and exocrine insufficiency, which are increasingly recognized long-term complications 4
• Surveillance for pancreatic cancer in patients with hereditary pancreatitis, starting at age 40 or 10 years earlier than the youngest affected relative 1

Common Pitfalls to Avoid

1. Overly aggressive fluid resuscitation, which increases risk of fluid overload without improving outcomes 2
2. Delayed enteral nutrition or unnecessary use of total parenteral nutrition 4
3. Routine use of prophylactic antibiotics in sterile necrosis 1
4. Unnecessary ERCP in the absence of cholangitis 4
5. Delayed diagnosis (should be made within 48 hours of admission) 1