What is the management approach for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires stratification based on severity, with severe cases requiring intensive care management, aggressive fluid resuscitation, nutritional support, and careful monitoring for complications. 1

Initial Assessment and Severity Classification

• 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 for mild cases includes regular assessment of vital signs, while severe cases require continuous monitoring of pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Severe cases require peripheral venous access, central venous line, urinary catheter, and nasogastric tube placement 1
• The etiology of acute pancreatitis should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic" 2

Fluid Resuscitation

• Moderate fluid resuscitation is preferred over aggressive hydration, as aggressive resuscitation has been associated with higher incidence of fluid overload without improvement in clinical outcomes 3
• Aim for fluid resuscitation that maintains urine output >0.5 ml/kg body weight 1
• Ringer's lactate has advantages over normal saline for fluid resuscitation 4
• 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 and should be addressed promptly 1
• A multimodal pain management approach including epidural analgesia is recommended to reduce opiate-related side effects 1, 4
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

Nutritional Support

• Early enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1, 5
• In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 5
• A normal "on-demand" diet has a positive effect on recovery and length of hospital stay 4
• Both gastric and jejunal feeding can be delivered safely in pancreatitis patients 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, 5
• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths 1
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 2, 1
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone, although the optimal choice and duration remains unclear 4
• Markers such as procalcitonin may help limit unwarranted antibiotic use 4

Management of Biliary Causes

• Urgent therapeutic ERCP should be performed within 24 hours of admission in patients with acute pancreatitis of suspected or proven gallstone etiology who have severe pancreatitis, cholangitis, jaundice, or a dilated common bile duct 1, 5
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1
• NSAIDs are recommended for prevention of post-ERCP pancreatitis 4

Imaging

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 2, 1
• Dynamic CT scanning should be obtained in severe cases to identify pancreatic necrosis and guide management 1
• When the etiology remains obscure, a CT scan should be performed (particularly in the elderly) to exclude a pancreatic tumor 2

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate 1
• Delay drainage of infected necrosis as much as possible, preferably for 4 weeks, to allow the development of a wall around the necrosis 1, 5, 4
• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension 5
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1
• Fresh frozen plasma should not be routinely administered for elevated INR in patients with pancreatitis 6

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 of severe cases 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 1
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1