What is the management of acute necrotizing pancreatitis?

Management of Acute Necrotizing Pancreatitis

Patients with acute necrotizing pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support, with interventions for infected necrosis delayed until at least 4 weeks after disease onset when possible. 1, 2

Initial Assessment and Management

• All patients with severe acute pancreatitis should be managed in an HDU or ICU setting with comprehensive monitoring including hourly assessment of vital signs, respiratory status, and urine output 1, 2
• Oxygen saturation should be measured continuously with supplemental oxygen administered to maintain arterial saturation >95% 3, 4
• Adequate fluid resuscitation with crystalloids (preferably Lactated Ringer's solution) should be initiated immediately to maintain urine output >0.5 ml/kg/hr 3, 4
• Pain management should follow a multimodal approach, with intravenous opiates used judiciously 3, 2

Nutritional Support

• Enteral nutrition is strongly preferred over parenteral nutrition to prevent gut failure and infectious complications 3, 2
• Both gastric and jejunal feeding routes can be safely utilized, with early initiation (within 24-48 hours) recommended 3, 2
• Total parenteral nutrition should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 3

Antibiotic Management

• Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection 2
• If antibiotic prophylaxis is used in severe cases with evidence of pancreatic necrosis, it should be limited to a maximum of 14 days 1, 3
• Antibiotics should be administered promptly when specific infections are confirmed 2, 5

Imaging and Assessment of Necrosis

• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess the extent of pancreatic necrosis 3, 2
• Patients with persistent organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require CT imaging 1
• All patients with persistent symptoms and >30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration for culture 7-14 days after onset 1, 2

Management of Infected Necrosis

• Interventions for infected necrosis should be delayed until at least 4 weeks after disease onset when possible, as this results in lower mortality 1, 6
• A step-up approach should be implemented, starting with percutaneous or endoscopic drainage and progressing to minimally invasive necrosectomy if no improvement occurs 1, 6
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 1
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1

Indications for Intervention

Early Intervention (before 4 weeks):

• Abdominal compartment syndrome unresponsive to conservative management 1
• Acute ongoing bleeding when endovascular approach is unsuccessful 1
• Bowel ischemia or acute necrotizing cholecystitis 1

Late Intervention (after 4 weeks):

• Infected necrosis with clinical deterioration 1, 7
• Ongoing organ failure without signs of infected necrosis 1
• Symptomatic or growing pseudocyst 1
• Disconnected duct syndrome 1

Management of Biliary Pancreatitis

• Urgent ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who have cholangitis, jaundice, or a dilated common bile duct 1, 3
• The procedure is best carried out within the first 72 hours after the onset of pain 1
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks 1

Referral Considerations

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications who may require intensive therapy unit care, or interventional radiological, endoscopic, or surgical procedures 1, 2
• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1

Common Pitfalls to Avoid

• Performing early surgical intervention (within first 4 weeks) for infected necrosis when patient is stable enough to wait 1, 6
• Using hydroxyethyl starch (HES) fluids in resuscitation 3, 4
• Aggressive fluid resuscitation leading to fluid overload 4, 8
• Relying solely on parenteral nutrition when enteral feeding is possible 3, 2
• Routine use of prophylactic antibiotics in all cases of necrotizing pancreatitis 3, 2