What are the management strategies for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires intensive monitoring, aggressive fluid resuscitation with Lactated Ringer's solution, early enteral nutrition, pain control, and appropriate intervention for complications. 1

Initial Assessment and Management

• All patients with severe acute pancreatitis should be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support 1
• Basic monitoring requirements include regular hourly assessment of vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Continuous vital signs monitoring in high dependency care unit is needed if organ dysfunction occurs 1
• Peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube should be placed in severe cases 1

Fluid Resuscitation

• Aggressive fluid resuscitation is crucial in preventing systemic complications and should be initiated promptly 1
• Lactated Ringer's solution is superior to normal saline for fluid resuscitation as it reduces severity, mortality, systemic and local complications by 31% and mortality by 62% 2
• Fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion 1

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1
• No evidence supports restrictions in pain medication, though NSAIDs should be avoided in acute kidney injury 1
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia in a multimodal approach 1
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1
• Both gastric and jejunal feeding can be delivered safely 1
• Early enteral nutrition should be initiated, even in severe cases 1
• TPN should be avoided but partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

• Prophylactic antibiotics are not recommended in mild cases of acute pancreatitis 1
• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths 1
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases 1
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1

Management of Biliary Causes

• Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who have severe pancreatitis, 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 undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1

Imaging

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1
• Dynamic CT scanning should be obtained in severe cases to identify pancreatic necrosis and guide management 1
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1

Management of Complications

Pancreatic Necrosis

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 1
• Surgical debridement may be necessary for infected necrosis 1
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1

Local Complications

• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team 1

Specific Pharmacological Treatment

• No specific pharmacological treatment except for organ support and nutrition has proven effective 1
• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1

Specialist Care

• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 1
• A multidisciplinary team approach is essential for optimal management 1

Monitoring and Follow-up

• Regular monitoring of vital signs and laboratory parameters is essential 1
• Follow-up imaging is recommended to monitor the resolution of collections in severe cases 3
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1