What is the treatment for necrotizing pancreatitis?

Treatment of Necrotizing Pancreatitis

The management of necrotizing pancreatitis requires a staged, multidisciplinary, step-up approach with initial conservative management followed by minimally invasive interventions only when necessary, particularly for infected necrosis. 1

Initial Management

• All patients with necrotizing pancreatitis should be managed in a high dependency unit (HDU) or intensive care unit (ICU) with comprehensive monitoring including hourly assessment of vital signs 1
• Aggressive fluid resuscitation is crucial in preventing systemic complications, with crystalloid or colloid administered to maintain urine output >0.5 ml/kg body weight 2
• Oxygen supplementation should be provided to maintain arterial saturation >95% 2
• Enteral nutrition is preferred over parenteral nutrition and should be initiated early via nasogastric or nasojejunal tube to prevent gut failure and infectious complications 1

Antibiotic Management

• Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection 1
• Antibiotics should only be administered when specific infections occur, particularly infected necrosis 1
• If antibiotic prophylaxis is used in severe cases, it should be limited to a maximum of 14 days 1

Diagnostic Approach

• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess the extent of necrosis 1
• Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 2
• Patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided fine needle aspiration to diagnose infected necrosis 1

Management of Pancreatic Necrosis

Sterile Necrosis

• Most patients with sterile necrosis can be managed conservatively with supportive care 3, 4
• Focus on fluid resuscitation, nutritional support, and monitoring for complications 1

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, 5
• A step-up approach should be implemented: 1, 3
  1. Initial percutaneous catheter or endoscopic drainage
  2. If no improvement, progress to minimally invasive necrosectomy (video-assisted retroperitoneal debridement or endoscopic necrosectomy)
  3. Open necrosectomy only as a last resort for patients not responding to minimally invasive approaches

Indications for Early Intervention

• Abdominal compartment syndrome unresponsive to conservative management 1
• Acute ongoing bleeding when endovascular approach is unsuccessful 1
• Bowel ischemia or acute necrotizing cholecystitis 1
• Infected necrosis with clinical deterioration 1, 6

Special Considerations for Biliary Pancreatitis

• Urgent ERCP should be performed in patients with acute biliary pancreatitis who have cholangitis, jaundice, or a dilated common bile duct 1
• The procedure should be 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 or within two weeks 1

Monitoring and Follow-up

• Regular assessment of vital signs, respiratory status, and urine output 1
• Monitoring for development of organ failure and local complications 2
• Follow-up imaging should be performed if clinical deterioration occurs or to detect asymptomatic complications before discharge 2

Referral Considerations

• Patients with extensive necrotizing pancreatitis or with other complications should be referred to a specialist unit with expertise in interventional radiology, endoscopy, and pancreatic surgery 1
• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1