What is the management for acute pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis should focus on aggressive fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, appropriate pain management, and targeted interventions for gallstone pancreatitis including urgent ERCP for severe cases with cholangitis. 1, 2, 3

Initial Assessment and Resuscitation

Fluid Resuscitation

• Use Lactated Ringer's solution as the preferred fluid type 1, 3
• Implement goal-directed fluid resuscitation protocol, avoiding overly aggressive fluid administration 4
• Monitor response to fluid therapy within the first 24-48 hours

Pain Management

• First-line: Opioid analgesics (do not increase risk of complications) 1
• Adjunctive therapy: Multimodal analgesia with paracetamol and NSAIDs/COX-2 inhibitors 1
• Consider mid-thoracic epidural analgesia for severe cases 1
• For neuropathic pain: Consider gabapentin, pregabalin, nortriptyline, or duloxetine 1

Nutritional Support

• Early enteral nutrition is preferred over parenteral nutrition 1, 4
  • Preserves gut mucosa integrity
  • Stimulates intestinal motility
  • Prevents bacterial overgrowth
  • Increases splanchnic blood flow
• When reinitiating oral feeding in mild cases, start with a low-fat, soft diet 1
• Consider pancreatic enzyme supplements to maintain weight and improve quality of life 1

Severity-Based Management

Mild Acute Pancreatitis

• Fluid resuscitation, pain control, and early enteral nutrition
• Early aggressive fluid therapy appears to have the highest benefit in mild cases 2

Severe Acute Pancreatitis

• Manage in High Dependency Unit (HDU) or Intensive Therapy Unit (ITU) setting with full monitoring and systems support 5
• Avoid overly aggressive fluid resuscitation in predicted severe disease as it might be futile or harmful 2, 4
• Monitor for complications including pancreatic necrosis and organ failure

Imaging and Diagnostic Workup

• Dynamic CT scanning with non-ionic contrast within 3-10 days of admission 5
• Pre-procedural dynamic CT helps identify vascular structures and assess collection wall 1
• Transabdominal ultrasound to identify gallstones as potential etiology 6

Management of Gallstone Pancreatitis

Urgent ERCP Indications

• Severe gallstone pancreatitis with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) requires immediate therapeutic ERCP 5, 1
• Urgent ERCP with biliary sphincterotomy and stone extraction within 72 hours (within 24 hours for patients with severe sepsis or septic shock) 1
• Failure of patient's condition to improve within 48 hours despite intensive resuscitation 5

Cholecystectomy Timing

• For mild gallstone pancreatitis: Laparoscopic cholecystectomy within 2-4 weeks of the attack, preferably during the same hospital admission to prevent recurrence 5, 1
• For severe acute pancreatitis: Delay cholecystectomy until later stage when inflammation has resolved 5

Management of Pancreatic Collections

• Pre-procedural assessment to evaluate collection characteristics (walled-off pancreatic necrosis, pseudocyst, mixed collection) 1
• For drainage procedures, ensure the distance between enteral wall and collection is less than 10 mm 1
• Use Color Doppler during procedures to identify and avoid blood vessels in the puncture path 1
• Remove metal stents used for EUS-guided drainage within 4 weeks to avoid complications 1

Prevention of Complications

• Avoid prophylactic antibiotics except in cases involving greater than 30% necrosis 4, 7
• Target glucose levels between 150-180 mg/dL during acute illness to avoid hypoglycemia 1
• For hypertriglyceridemia-induced pancreatitis, aim for triglyceride levels less than 500 mg/dL, ideally less than 150 mg/dL 1

Common Pitfalls and Caveats

• Avoid total parenteral nutrition when possible 4
• Avoid ERCP in the absence of concomitant cholangitis 4
• Aggressive fluid resuscitation may be harmful in severe pancreatitis 2, 4
• Centers performing advanced procedures should have support from interventional radiologists, surgeons, and anesthesiologists to manage potential complications 1
• Monitor for development of diabetes and exocrine insufficiency after acute pancreatitis, which occur at unexpectedly high rates 4