What are the guidelines for managing acute pancreatitis?

Guidelines for Management of Acute Pancreatitis

The management of acute pancreatitis requires stratification by severity, with mild cases managed on general wards with basic monitoring and severe cases requiring high dependency or intensive care unit management with full systems support. 1, 2

Classification and Initial Assessment

• Acute pancreatitis is classified as mild (80% of cases, <5% mortality) or severe (20% of cases, up to 95% of deaths) based on objective criteria 2
• Diagnosis requires at least two of three criteria: upper abdominal pain, elevated serum lipase/amylase, and consistent abdominal imaging 2, 3
• Initial laboratory assessment should include pancreatic enzymes, liver function tests, white blood cell count, C-reactive protein, and procalcitonin (PCT is most sensitive for detecting pancreatic infection) 2
• Severity stratification should be made in all patients within 48 hours of diagnosis 1

Management of Mild Acute Pancreatitis

• Patients with mild pancreatitis can be managed on a general ward with basic monitoring of vital signs 2
• Intravenous fluid resuscitation should be administered via peripheral venous access 2, 4
• Lactated Ringer's solution is preferred over normal saline as it reduces systemic inflammation 5, 6
• Moderate fluid resuscitation is preferred over aggressive resuscitation to avoid fluid overload 7
• Antibiotics should NOT be administered routinely in mild cases as there's no evidence they improve outcomes 2
• Regular diet can be advanced as tolerated with oral pain medications 2
• Routine CT scanning is unnecessary unless clinical deterioration occurs 2

Management of Severe Acute Pancreatitis

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 1, 2
• Initial management requires full resuscitation and a multidisciplinary approach 2
• Required monitoring includes:
  • Peripheral venous access 2
  • Central venous line for fluid administration and CVP monitoring 2
  • Urinary catheter 2
  • Nasogastric tube 2
  • Regular arterial blood gas analysis 2
• Oxygen saturation should be continuously monitored with supplemental oxygen administered to maintain arterial saturation >95% 2
• Enteral nutrition (oral, nasogastric, or nasojejunal) should be provided rather than parenteral nutrition 2
• Dynamic CT scanning with non-ionic contrast should be obtained within 3-10 days of admission 1, 2
• Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 2

Management of Gallstone Pancreatitis

• For severe gallstone pancreatitis, urgent ERCP and sphincterotomy is indicated if the patient's condition fails to improve within 48 hours despite intensive resuscitation 2, 3
• Immediate therapeutic ERCP is required in the presence of increasingly deranged liver function tests and signs of cholangitis 2, 3
• ERCP should always be performed under antibiotic cover 2, 3
• 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 1

Fluid Resuscitation

• Moderate fluid resuscitation is preferred over aggressive resuscitation to prevent fluid overload 7
• Lactated Ringer's solution is superior to normal saline in reducing systemic inflammatory response syndrome (SIRS) in the first 24 hours 5, 6
• For mild-moderate cases, moderate fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg (if hypovolemic) is recommended 7

Monitoring Coagulation Parameters

• Regular monitoring of coagulation parameters is essential in severe pancreatitis as part of comprehensive assessment 8
• For mild-moderate INR elevation (<5.0) without bleeding, withhold any anticoagulant medications and observe 8
• For significant INR elevation (INR 5.0-9.0) without bleeding, consider oral vitamin K (1.0-2.5 mg) and monitor INR closely 8

Common Pitfalls to Avoid

• Routine use of antibiotics in mild pancreatitis 2
• Aggressive fluid resuscitation leading to fluid overload 7
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 2, 3
• Failing to provide adequate nutritional support 2
• Failing to stratify severity within 48 hours of diagnosis 1
• Failing to determine etiology (idiopathic cases should not exceed 20-25% of total) 1