What is the treatment for pancreatitis?

Treatment for Pancreatitis

The treatment of pancreatitis should focus on aggressive fluid resuscitation, oxygen supplementation, nutritional support, and specialized care in severe cases, with management in a high dependency or intensive care unit for severe cases. 1

Initial Assessment and Classification

• Pancreatitis is classified as mild (80% of cases, <5% of deaths) or severe (20% of cases, 95% of deaths) based on objective criteria 1
• Diagnosis requires two of: upper abdominal pain, elevated amylase/lipase (≥3× upper limit of normal), and/or characteristic imaging findings 2
• Laboratory assessment should include lipase (preferred over amylase), C-reactive protein, and other markers to determine severity 3, 1
• Patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission require contrast-enhanced CT imaging 3

Management of Mild Acute Pancreatitis

• Patients can be managed on a general ward with monitoring of vital signs 1
• Early aggressive intravenous hydration with Lactated Ringer's solution has been shown to hasten clinical improvement 4, 5
• Oxygen saturation should be continuously monitored with supplemental oxygen to maintain arterial saturation >95% 3
• Regular diet can be advanced as tolerated with appropriate pain management 1
• Routine CT scanning is unnecessary unless clinical deterioration occurs 3, 1

Management of Severe Acute Pancreatitis

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 3
• Fluid resuscitation is crucial in preventing systemic complications, with moderate fluid resuscitation preferred over aggressive resuscitation 1, 5
• Enteral nutrition is preferred over parenteral nutrition when nutritional support is required 3, 1
• The nasogastric route for feeding can be used as it appears to be effective in 80% of cases 3
• Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 3

Antibiotic Use in Pancreatitis

• There is no consensus on antibiotic prophylaxis in severe acute pancreatitis; evidence is conflicting 3
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 3
• Procalcitonin-based algorithms may help guide antibiotic use to distinguish between inflammation and infection 6, 5
• There is no proven specific drug therapy for the treatment of acute pancreatitis 3

Management of Gallstone Pancreatitis

• Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology with severe disease, cholangitis, jaundice, or a dilated common bile duct 3
• ERCP is best carried out within the first 72 hours after the onset of pain 3
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for treatment within two weeks 3

Management of Pancreatic Necrosis

• All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 3
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 3
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 3

Common Pitfalls to Avoid

• Routine use of antibiotics in mild pancreatitis 1
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 1
• Failing to provide adequate nutritional support 1
• Overuse of CT scanning in mild cases with clinical improvement 3, 1