What is the management approach for pancreatitis?

Management of Acute Pancreatitis

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

Initial Assessment and Management

• Patients should be stratified by severity to determine appropriate level of care, with severe cases requiring HDU/ICU admission 1
• Basic monitoring requirements include hourly assessment of vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Peripheral venous access, central venous line, urinary catheter, and nasogastric tube should be placed in severe cases 1

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 2
• Lactated Ringer's solution is preferred over normal saline as it may help correct metabolic acidosis and has anti-inflammatory effects 3
• Fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1
• Aggressive fluid resuscitation has been shown to increase risk of fluid overload without improving clinical outcomes 2

Pain Management

• Pain control is a clinical priority and should be addressed promptly using a multimodal approach 1
• Hydromorphone (Dilaudid) is 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 4

Nutritional Support

• Early enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1
• Both gastric and jejunal feeding can be delivered safely 1
• In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 5
• 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
• The procedure should be performed 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
• Cholecystectomy should be performed within 2-4 weeks for mild gallstone pancreatitis, preferably during the same hospital admission to prevent recurrent attacks 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 5
• In stable patients with infected necrosis, drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 5

Pitfalls to Avoid

• Relying solely on clinical assessment without regular blood gas monitoring, as this may lead to delayed recognition of worsening acidosis 4
• Using hydroxyethyl starch (HES) fluids for resuscitation, which should be avoided in acute pancreatitis 4
• Aggressive fluid resuscitation, which can lead to fluid overload without improving outcomes 2
• Delaying enteral nutrition unnecessarily, which can lead to increased infectious complications 1
• Performing unnecessary interventions for asymptomatic collections 5