What are the symptoms and treatment options for pancreatitis?

Symptoms and Treatment of Pancreatitis

The primary symptoms of pancreatitis include severe, persistent epigastric pain radiating to the back, which is a key distinguishing feature, along with elevated lipase levels (at least three times normal) and characteristic findings on imaging. 1

Symptoms of Pancreatitis

• Severe, persistent epigastric pain radiating to the back is the hallmark symptom of pancreatitis 1
• Fever may be present in severe cases 1
• Nausea and vomiting are common accompanying symptoms 2
• Abdominal tenderness on examination, particularly in the epigastric region 2

Diagnosis

• Diagnosis requires two of three criteria: characteristic abdominal pain, elevated lipase (preferred over amylase) at least three times normal, and imaging findings of pancreatic inflammation 3
• Lipase is preferred over amylase for diagnosis due to better diagnostic accuracy 3
• When diagnosis remains unclear, contrast-enhanced CT provides definitive evidence for presence or absence of pancreatitis 4
• Etiology should be determined in at least 80% of cases, with no more than 20% classified as idiopathic 4

Severity Assessment

• The Atlanta criteria define severity of pancreatitis, recognizing that organ failure resolving within 48 hours should not indicate severe pancreatitis 3
• Important 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 3
• Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6–10 days after admission require computed tomography 4

Treatment Approach

Initial Management

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 4
• Fluid resuscitation is essential for stabilizing cardiovascular dynamics, with dose adjusted while assessing circulatory dynamics constantly 5
• Pain control with intravenous opiates is generally safe if used judiciously 2
• Early oral feeding within 24 hours as tolerated rather than keeping patients nil per os is recommended 3

Nutritional Support

• If nutritional support is required, the enteral route should be used if tolerated 4
• Nasogastric feeding is effective in approximately 80% of cases and can be used instead of nasojejunal feeding 4
• Enteral feeding is superior to parenteral nutrition for nutritional support in severe acute pancreatitis 5

Antibiotic Management

• The evidence regarding antibiotic prophylaxis against infection of pancreatic necrosis is conflicting 4
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 4
• Prophylactic antibiotics are recommended in patients with severe acute pancreatitis to prevent infectious complications 5

Management of Gallstone Pancreatitis

• 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 4
• The procedure is best carried out within the first 72 hours after the onset of pain 4
• 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 4

Management of Pancreatic Necrosis

• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration to obtain material for culture 4
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 4
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 4

Common Pitfalls to Avoid

• Avoiding delaying diagnosis beyond 48 hours of admission 3
• Avoiding aggressive fluid resuscitation rates that may lead to fluid overload 3
• Avoiding early surgical intervention (<4 weeks) for pancreatic necrosis, which results in higher mortality 3
• Failing to provide adequate pain control, which can lead to increased stress response and potentially worsen outcomes 2