What are the symptoms and treatment options for pancreatitis?

Symptoms and Treatment of Pancreatitis

Symptoms of Pancreatitis

The primary symptoms of acute pancreatitis include upper abdominal pain and vomiting, accompanied by epigastric or diffuse abdominal tenderness. 1 These classic symptoms may be accompanied by:

• Severe epigastric pain that may radiate to the back
• Nausea and vomiting
• Abdominal tenderness on examination
• Occasionally, body wall ecchymoses (Cullen's sign at the umbilicus, Grey-Turner's sign in the flanks) 1
• Fever
• Tachycardia

Diagnostic Criteria

Diagnosis of acute pancreatitis 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 2

Treatment of Pancreatitis

Initial Management

1. Aggressive hydration should be provided to all patients with acute pancreatitis, unless cardiovascular and/or renal comorbidities preclude it. 3

   • Most beneficial within first 12-24 hours
   • Monitor for fluid overload

2. Pain management:

   • Begin with non-opioid medications (acetaminophen)
   • Progress to oral opioids if inadequate pain control
   • Patient-controlled analgesia for severe cases 2

3. Nutritional support:

   • In mild pancreatitis, oral feeding can start immediately if no nausea/vomiting
   • In severe pancreatitis, enteral nutrition is recommended over parenteral nutrition 3
   • Target: 25-35 kcal/kg/day and 1.2-1.5 g/kg/day protein 2

Management Based on Etiology

Gallstone Pancreatitis

• Early cholecystectomy during initial hospitalization for mild biliary pancreatitis is recommended 2
• If cholecystectomy cannot be performed during hospitalization, schedule within 2-4 weeks after discharge 2
• ERCP with sphincterotomy within 24 hours for patients with concurrent acute cholangitis 3

Alcoholic Pancreatitis

• Alcohol cessation counseling
• Nutritional support
• Treatment of complications

Management of Complications

1. Pancreatic necrosis:

   • Patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided FNA for culture 1
   • In stable patients with infected necrosis, drainage should be delayed for approximately 4 weeks 3
   • Minimally invasive approaches to infected necrosis are preferred 4

2. Pancreatic pseudocysts:

   • Asymptomatic pseudocysts do not warrant intervention regardless of size, location, or extension 3
   • Conservative management with bowel rest and nutrition may resolve some pseudocysts 5

3. Exocrine pancreatic insufficiency:

   • May require pancreatic enzyme replacement therapy
   • Monitor for adverse reactions including fibrosing colonopathy, irritation of oral mucosa, hyperuricemia 6

Monitoring and Assessment

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit 1
• Contrast-enhanced CT is the diagnostic standard for radiologic evaluation, especially for assessing disease severity 7
• Regular monitoring of vital signs, urine output, and laboratory parameters
• Overall mortality should be lower than 10%, and less than 30% in severe disease 2

Follow-up Care

• Regular follow-up every 6-12 months to evaluate pain control, nutritional status, complications, and quality of life 2
• For patients with gallstone pancreatitis who haven't undergone cholecystectomy, definitive treatment should not be delayed more than two weeks after discharge 1

Pitfalls and Caveats

1. Avoid prophylactic antibiotics in patients with severe acute pancreatitis and/or sterile necrosis 3

2. Avoid total parenteral nutrition when possible, as enteral nutrition is associated with lower rates of complications 7

3. Do not delay cholecystectomy in mild gallstone pancreatitis, as there is significant risk of recurrence 2

4. Recognize that the clinical diagnosis of pancreatitis may be unreliable if made on clinical findings alone; laboratory confirmation with amylase/lipase is important 1

5. Be aware that pancreatic enzyme replacement therapy can cause adverse reactions including hypersensitivity reactions, fibrosing colonopathy, and irritation of oral mucosa 6