What is the management approach for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires aggressive fluid resuscitation, early enteral nutrition, pain control, and appropriate level of care based on severity, with severe cases requiring HDU/ICU admission and multidisciplinary specialist care. 1

Initial Assessment and Management

Severity Assessment and Level of Care

• All cases of severe acute pancreatitis should be managed in a High Dependency Unit (HDU) or Intensive Care Unit (ICU) with full monitoring and systems support 2, 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 is preferred over aggressive resuscitation to prevent fluid overload complications 3
• Aim to maintain urine output >0.5 ml/kg body weight 1
• Lactated Ringer's solution is preferred over normal saline 4
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion 1, 5

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1
• A multimodal approach including epidural analgesia should be considered to reduce opiate-related side effects 1, 4
• Patient-controlled analgesia (PCA) should be integrated with pain management strategy 1
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1

Nutritional Support

• Enteral nutrition is strongly recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1, 6
• Early oral feeding can be started immediately in mild pancreatitis if there is no nausea and vomiting 6
• Both gastric and jejunal feeding can be delivered safely 1
• TPN should be avoided but may be necessary if ileus persists for more than five days 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 2, 1, 7
• The procedure is best 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 2, 1
• Cholecystectomy should be performed within 2-4 weeks in mild gallstone pancreatitis to prevent recurrence 2

Antibiotic Therapy

• Prophylactic antibiotics are not recommended in mild cases of acute pancreatitis 1, 6
• 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
• Procalcitonin may be used to guide antibiotic therapy decisions 4

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 1

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate 1
• Delay drainage of infected necrosis as much as possible, as this is associated with fewer procedures 4
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1, 4
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1
• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension 6

Special Considerations

Coagulopathy Management

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

Gastric Outlet Dysfunction

• Early enteral feeding is recommended even in patients with gastric outlet dysfunction 7
• Goal-directed fluid resuscitation is essential in all patients with acute pancreatitis 7

Pitfalls and Caveats

• Avoid aggressive fluid resuscitation as it can lead to fluid overload without improving clinical outcomes 3
• Avoid routine use of prophylactic antibiotics in patients with mild pancreatitis or sterile necrosis 1, 6
• Avoid parenteral nutrition when enteral nutrition is possible 1, 6
• Do not intervene on asymptomatic pancreatic collections regardless of size 6
• In stable patients with infected necrosis, drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 6