What is the management approach for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires prompt assessment of severity, with all severe cases requiring intensive care unit (ICU) or high dependency unit (HDU) management with full monitoring and systems support. 1

Initial Assessment and Management

• All patients with severe acute pancreatitis should be managed in an HDU or ICU setting with continuous monitoring of vital signs including pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Basic monitoring equipment should include peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube in severe cases 1
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 2

Fluid Resuscitation

• Moderate fluid resuscitation at a rate of 1.5 ml/kg/hr following an initial bolus of 10 ml/kg is preferred over aggressive fluid resuscitation 3
• Lactated Ringer's solution is preferred over normal saline as it may help correct metabolic acidosis and is associated with an anti-inflammatory effect 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 and should be addressed promptly 1
• A multimodal approach to pain management is recommended, with hydromorphone (Dilaudid) preferred over morphine or fentanyl in non-intubated patients 1
• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia 1
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1
• NSAIDs should be avoided in patients with acute kidney injury 2

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1
• In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 4
• Early enteral nutrition should be initiated even in severe cases 1
• Both gastric and jejunal feeding can be delivered safely 1
• If ileus persists for more than five days, parenteral nutrition will be required 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
  • Dilated common bile duct 1, 5
• 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
• Ideally, patients with mild gallstone pancreatitis should have their gallstones eradicated by laparoscopic (or open) cholecystectomy within two to four weeks 6

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 choice for prophylaxis in severe cases 1
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 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

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 1
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1
• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension 4
• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 4

Special Considerations

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

Pitfalls to Avoid

• Aggressive fluid resuscitation can lead to fluid overload in 20.5% of patients compared to 6.3% with moderate resuscitation 3
• Relying solely on clinical assessment without regular blood gas monitoring may lead to delayed recognition of worsening acidosis 2
• Delaying enteral nutrition unnecessarily can increase the risk of infectious complications 1
• Using hydroxyethyl starch fluids for resuscitation should be avoided in acute pancreatitis 2