What is the management of acute pancreatitis?

From the Guidelines

Management of acute pancreatitis requires prompt supportive care, including aggressive intravenous fluid resuscitation, pain control, and early enteral nutrition, as well as monitoring for complications and addressing the underlying cause of pancreatitis. The initial management should focus on supporting organ function and preventing complications, rather than trying to halt the inflammatory cascade, which currently has no specific treatment.

Key Components of Management

• Aggressive intravenous fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr in the first 24 hours, with reassessment based on vital signs, urine output, and BUN levels 1
• Pain control using opioid analgesics like morphine (2-4 mg IV every 4 hours) or hydromorphone (0.5-1 mg IV every 4 hours)
• Early enteral nutrition initiated within 24-48 hours via oral, nasogastric, or nasojejunal routes if tolerated, to maintain gut barrier function and reduce infectious complications 1
• Close monitoring for organ failure using the modified Marshall scoring system, and for local complications such as pancreatic necrosis
• Antibiotics are not routinely recommended unless there is confirmed infected necrosis or other specific infections, and prophylactic antibiotics are no longer recommended for all patients with acute pancreatitis 1

Addressing Underlying Causes and Complications

• The underlying cause of pancreatitis, such as gallstone removal if biliary pancreatitis is present, should be addressed
• Severe cases may require ICU admission, and interventions for complications like infected necrosis should be delayed until 4 weeks if possible, allowing for walled-off necrosis to develop
• Endoscopic retrograde cholangiopancreatography (ERCP) should be performed as soon as possible in patients with acute biliary pancreatitis and common bile duct obstruction 1

Recent Guidelines and Recommendations

• The 2019 WSES guidelines for the management of severe acute pancreatitis provide evidence-based international consensus statements on diagnosis, management in the ICU, surgical and operative management, open abdomen, and antibiotic treatment 1
• The Italian Council for the Optimization of Antimicrobial Use recommends enteral nutrition, IV pain medications, early fluid resuscitation, and mechanical ventilation for severe acute pancreatitis, with no specific pharmacological treatment except for organ support and nutrition 1

From the Research

Management of Acute Pancreatitis

The management of acute pancreatitis involves several key components, including:

• Aggressive intravenous fluid resuscitation, which is generally recommended in all patients with acute pancreatitis 2, 3, 4
• The use of crystalloids, such as lactated Ringer's solution, as the preferred fluid for resuscitation 2, 5, 6
• Early recognition of severity and institution of intensive care with close monitoring and support of organ function in patients with severe acute pancreatitis 3
• Antibiotic prophylaxis and early supportive treatment of organ failure in severe cases 3
• Surgery in selected cases with infected pancreatic necrosis or deterioration of patient's condition despite maximal conservative therapy 3
• Early endoscopic removal of common bile duct stones in cases with biliary acute pancreatitis 3

Fluid Resuscitation

The optimal rate, type, and goal of fluid resuscitation in acute pancreatitis remain unclear 2, 4. However, studies suggest that:

• Aggressive fluid resuscitation may be beneficial in improving outcomes, but its association with improved outcomes is not well established 5
• Moderate fluid resuscitation may be as effective as aggressive fluid resuscitation in some cases 5
• Fluid therapy based on Ringer's lactate may improve the course of the disease, but further studies are needed to confirm this possibility 6

Monitoring and Adjustment

Fluid resuscitation should be adjusted based on the patient's clinical and analytical status, with monitoring of parameters such as hematocrit, blood urea nitrogen, and creatinine 2, 5. Invasive monitoring of hemodynamic parameters may not be necessary in most patients with acute pancreatitis 6.