What is the treatment for pancreatitis?

Treatment of Pancreatitis

The treatment of pancreatitis should be stratified based on severity, with mild cases requiring supportive care while severe cases need intensive monitoring and intervention in an HDU or ITU setting. 1

Classification and Initial Assessment

• Pancreatitis is classified as mild (80% of cases, <5% of deaths) or severe (20% of cases, 95% of deaths) based on objective criteria 1
• Laboratory markers for assessment include lipase, amylase, white blood cell count, C-reactive protein, and procalcitonin (PCT is most sensitive for detecting pancreatic infection) 1
• Imaging options include ultrasound, contrast-enhanced CT, MRI, and endoscopic ultrasound 1

Management of Mild Acute Pancreatitis

• Patients can be managed on a general ward with basic monitoring of vital signs 1
• Intravenous fluids should be administered via peripheral venous access, with possible nasogastric tube placement 1
• Antibiotics should NOT be administered routinely as there's no evidence they affect outcomes in mild cases 1
• Antibiotics are only warranted when specific infections occur (chest, urine, bile, or cannula-related) 1
• Regular diet can be advanced as tolerated with oral pain medications 1
• Routine CT scanning is unnecessary unless clinical deterioration occurs 1

Management of Severe Acute Pancreatitis

• All cases should be managed in an HDU or ITU setting with full monitoring and systems support 1

• Initial management requires full resuscitation and a multidisciplinary approach 1

• Required monitoring includes:

  • Peripheral venous access
  • Central venous line for fluid administration and CVP monitoring
  • Urinary catheter
  • Nasogastric tube
  • Regular arterial blood gas analysis
  • Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1

• Fluid resuscitation:

  • Adequate prompt fluid resuscitation is crucial in preventing systemic complications 1
  • Moderate fluid resuscitation is preferred over aggressive resuscitation, as aggressive resuscitation results in higher incidence of fluid overload without improving clinical outcomes 2
  • Lactated Ringer's solution is preferred over normal saline 3
  • Oxygen saturation should be continuously monitored with supplemental oxygen administered to maintain arterial saturation >95% 1

• Nutrition:

  • Enteral nutrition (oral, nasogastric, or nasojejunal) should be provided 1
  • If enteral nutrition is not tolerated, parenteral nutrition can be used 1

• Antibiotic therapy:

  • Routine prophylactic antibiotics are no longer recommended for all patients with acute pancreatitis 1
  • There is some evidence supporting prophylactic antibiotics in severe acute pancreatitis to prevent local and septic complications 1
  • If used, intravenous cefuroxime provides a reasonable balance between efficacy and cost 1
  • Antibiotics should always be used to treat confirmed infections 1

• Imaging:

  • Dynamic CT scanning with non-ionic contrast should be obtained within 3-10 days of admission 1
  • Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 1

Management of Gallstone Pancreatitis

• Treatment depends on severity, presence of jaundice, or cholangitis 1
• For severe gallstone pancreatitis:
  • Urgent ERCP and sphincterotomy is indicated if the patient's condition fails to improve within 48 hours despite intensive resuscitation 1
  • Immediate therapeutic ERCP is required in the presence of increasingly deranged liver function tests and signs of cholangitis 1
  • ERCP should always be performed under antibiotic cover 1

Special Considerations

• For patients with chronic pancreatitis:

  • Normal food supplemented by pancreatic enzymes is adequate for most patients 1
  • Diet should be rich in carbohydrates and protein (1.0-1.5 g/kg) with moderate fat (30% of calories) 1
  • Enteral nutrition is indicated if patients cannot ingest sufficient calories due to pain, anatomical obstruction, or weight loss despite adequate normal food intake 1

• Common pitfalls to avoid:

  • Overaggressive fluid resuscitation can lead to fluid overload and worse outcomes 2
  • Routine use of antibiotics in mild pancreatitis is not beneficial 1
  • Delaying ERCP in severe gallstone pancreatitis with cholangitis 1
  • Failing to provide adequate nutritional support 1