Key Teaching Points for Pancreatitis
The management of pancreatitis requires prompt diagnosis, accurate severity assessment, and appropriate interventions based on disease progression to reduce morbidity and mortality. 1
Diagnosis
- Diagnosis should be established within 48 hours of admission using lipase (preferred over amylase) for better diagnostic accuracy 1
- When diagnosis remains unclear, contrast-enhanced CT provides definitive evidence for presence or absence of pancreatitis 1
- Etiology should be determined in at least 80% of cases, with no more than 20% classified as idiopathic 1
Severity Assessment
- Use Atlanta criteria for severity definitions, recognizing that organ failure resolving within 48 hours should not indicate severe pancreatitis 1
- Prognostic indicators include clinical impression of severity, obesity, APACHE II score in first 24 hours, CRP >150 mg/L, Glasgow score ≥3, or persistent organ failure after 48 hours 1
- CT scanning is indicated for patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission 1
Fluid Management
- Use goal-directed therapy for fluid management, with non-aggressive resuscitation at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg 1, 2
- Avoid hydroxyethyl starch (HES) fluids as they may increase risk of multiple organ failure 1, 2
- Total crystalloid fluid administration should be less than 4000 ml in the first 24 hours to avoid fluid overload 3, 2
Nutritional Support
- Implement early oral feeding (within 24 hours) as tolerated rather than keeping patients nil per os 1, 4
- When oral feeding is not possible, use enteral rather than parenteral nutrition to prevent infectious complications 1, 4
- Nasogastric feeding is effective in approximately 80% of cases and can be used instead of nasojejunal feeding 1
Antibiotic Management
- Avoid routine prophylactic antibiotics in predicted severe or necrotizing pancreatitis 1, 4
- If antibiotic prophylaxis is used, limit duration to a maximum of 14 days 1
- Reserve antibiotics for cases with documented infection of pancreatic necrosis 5, 6
Management of Gallstone Pancreatitis
- Perform urgent ERCP within 72 hours in patients with gallstone pancreatitis who have cholangitis, jaundice, or dilated common bile duct 1
- All patients with gallstone pancreatitis should undergo definitive management of gallstones (usually cholecystectomy) during the same hospital admission or within two weeks 1
- Endoscopic sphincterotomy is required for all patients undergoing early ERCP for severe gallstone pancreatitis, regardless of whether stones are found 1
Management of Pancreatic Necrosis
- Patients with severe acute pancreatitis should be managed in high dependency or intensive care units with full monitoring and support 1, 5
- Perform image-guided fine needle aspiration for patients with >30% pancreatic necrosis or clinical suspicion of sepsis 1, 5
- Delay intervention for infected necrosis, preferably for 4 weeks, to allow wall formation around the necrosis 5, 4
- Complete debridement of all cavities containing necrotic material is necessary for infected necrosis 1, 5
Monitoring and Follow-up
- Conduct daily or more frequent reassessment to diagnose life-threatening complications early 3, 2
- Monitor oxygen saturation continuously and provide supplemental oxygen to maintain arterial saturation >95% 3, 2
- Perform follow-up CT scans only if the patient's clinical status deteriorates or fails to improve 3, 5
Prevention of Recurrence
- Provide brief alcohol intervention during admission for patients with alcoholic pancreatitis 1, 7
- Implement lipid-lowering medications in hypertriglyceridemia-induced pancreatitis 7
Common Pitfalls to Avoid
- Delaying diagnosis beyond 48 hours of admission 1
- Using aggressive fluid resuscitation rates that may lead to fluid overload 3, 2
- Early surgical intervention (<4 weeks) for pancreatic necrosis, which results in higher mortality 5, 6
- Relying solely on size as the criterion for intervention in pancreatic collections 5