What is the management of pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis should be stratified based on severity, with mild cases managed on general wards with basic monitoring and severe cases requiring intensive care unit or high dependency unit care with full monitoring and systems support. 1

Initial Assessment and Severity Stratification

• Severity stratification should be performed within 48 hours of admission using clinical impression, obesity, APACHE II score, C-reactive protein >150 mg/l, Glasgow score ≥3, or persisting organ failure 2
• The aetiology of acute pancreatitis should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic" 2
• Basic monitoring requirements include regular assessment of vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature 1

Management of Mild Acute Pancreatitis (80% of cases)

• Patients can be managed on general wards with basic monitoring of vital signs and urine output 2
• Management includes:
  • Peripheral intravenous line for fluid administration 2
  • Possibly a nasogastric tube (not all patients will require this) 2
  • Urinary catheter generally not warranted in mild cases 2
• Antibiotics should not be administered routinely in mild cases as there is no evidence they improve outcomes or reduce septic complications 2, 1
• Routine CT scanning is unnecessary unless clinical deterioration occurs 2

Management of Severe Acute Pancreatitis (20% of cases)

General Management

• All patients with severe acute pancreatitis should be managed in an ICU or HDU 2, 1
• Required monitoring includes:
  • Peripheral venous access
  • Central venous line for fluid administration and CVP monitoring
  • Urinary catheter
  • Nasogastric tube 1
• Strict asepsis should be maintained with invasive monitoring equipment to prevent infection in pancreatic necrosis 2
• When cardiocirculatory compromise exists, a Swan-Ganz catheter may be required 2
• Regular arterial blood gas analysis is essential to detect hypoxia and acidosis 2, 1

Fluid Resuscitation

• Moderate fluid resuscitation with lactated Ringer's solution is recommended over aggressive hydration with normal saline 3, 4, 5
• Goal-directed fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1, 6

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1
• A multimodal approach including epidural analgesia should be considered for moderate to severe pain 1, 6
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition to prevent gut failure and infectious complications 1, 4
• Early enteral feeding should be initiated, even in severe cases 1, 4
• Both gastric and jejunal feeding can be delivered safely 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

• The evidence regarding antibiotic prophylaxis in necrotizing pancreatitis is conflicting 2
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 2
• Procalcitonin may help guide antibiotic use to distinguish between inflammation and infection 4, 6
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 2, 1

Management of Biliary Causes

• Urgent therapeutic ERCP should be performed in patients with:
  • Acute pancreatitis of suspected or proven gallstone etiology with predicted or actual severe pancreatitis
  • Cholangitis
  • Jaundice
  • Dilated common bile duct 2, 1
• The procedure is best carried out within the first 72 hours after the onset of pain 2, 1
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 2
• 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 2

Management of Complications

• Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require CT scanning 2
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 2, 1
• A step-up approach is recommended for managing infected necrosis: antibiotics first, then drainage, then delayed minimally-invasive necrosectomy 5
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 2

Specialist Care

• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 2
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 2, 1

Common Pitfalls to Avoid

• Delaying drainage of infected collections, which can lead to sepsis and increased mortality 7
• Performing aggressive fluid resuscitation (>3mL/kg/h), which can worsen outcomes 5
• Using prophylactic antibiotics routinely in mild cases 2, 1
• Delaying enteral nutrition unnecessarily 1, 4
• Performing open surgical necrosectomy when minimally invasive approaches are available 5