What is the management for acute pancreatitis with pseudocysts and pancreatic necrosis?

Management of Acute Pancreatitis with Pseudocysts and Pancreatic Necrosis

Patients with extensive necrotising pancreatitis or with other complications should be managed in, or referred to, a specialist unit that can provide intensive care, interventional radiological, endoscopic, or surgical procedures as needed. 1

Initial Assessment and Management

• Classify severity using the Revised Atlanta Classification (Mild, Moderately severe, Severe)
• Repeat severity assessment within 48 hours as disease condition changes rapidly 2
• Use CT severity index for prognostication 2
• Provide conservative fluid resuscitation:
  • Fluid administration at <10 ml/kg/hour
  • Initial bolus of 10 ml/kg for 2 hours followed by 1.5 ml/kg/hour
  • Total crystalloid <4000 ml in first 24 hours 2
• Start early enteral nutrition within 24-72 hours of admission (25-35 kcal/kg/day and 1.2-1.5 g/kg/day protein) 2
• Manage pain with non-opioid medications initially, progressing to opioids if needed 2

Management of Pancreatic Necrosis

Antibiotic Management

• Do not administer prophylactic antibiotics for sterile necrosis 2, 3
• Reserve antibiotics for:
  • Culture-proven infection
  • Strong clinical suspicion of infection
• When needed, use antibiotics that penetrate pancreatic necrosis (carbapenems or quinolones with metronidazole) 2

Intervention for Necrosis

• For infected necrosis, intervention is required to completely debride all cavities containing necrotic material 1, 2
• Delay intervention for 4 weeks when possible to allow necrosis to become walled-off 2, 3
• Avoid early debridement (first 2 weeks) as it increases morbidity and mortality 2
• The choice of surgical technique depends on individual features and locally available expertise 1

Management of Pancreatic Pseudocysts

• Most pseudocysts resolve spontaneously with supportive care 4
• Indications for drainage:
  • Persistent symptoms
  • Complications (infection, gastric outlet or biliary obstruction, bleeding) 4

Drainage Options

• Endoscopic drainage is becoming the preferred approach because it:

  • Is less invasive than surgery
  • Avoids the need for external drain
  • Has a high long-term success rate 4

• Options include:

  1. Endoscopic drainage (transpapillary or transmural)
  2. Percutaneous catheter drainage
  3. Surgical drainage (open or laparoscopic)

• For pseudocysts with minimal debris (<30%), both endoscopic and laparoscopic approaches have similar efficacy (success rates of 90% and 93.3% respectively) 5

• For walled-off necrosis containing significant necrotic tissue, additional interventions may be required:

  • Endoscopic necrosectomy
  • Large-diameter metal stents
  • Hybrid approach with percutaneous drainage 6

Pitfalls and Caveats

1. Delayed recognition of infected necrosis: Monitor for signs of infection and obtain cultures when infection is suspected rather than using prophylactic antibiotics.

2. Premature intervention: Early debridement (within first 2 weeks) increases morbidity and mortality. Delay intervention for 4 weeks when possible to allow adequate walling-off of necrosis 2, 3.

3. Inadequate specialty care: Ensure patients with extensive necrotizing pancreatitis are managed in a specialized unit with appropriate expertise and resources 1.

4. Overreliance on parenteral nutrition: Enteral nutrition is superior to parenteral nutrition for preventing infectious complications 2, 3.

5. Failure to consider a step-up approach: For infected collections, consider a step-up approach starting with less invasive drainage before proceeding to more invasive necrosectomy if needed 6, 5.