What is the treatment approach for pancreatitis in India?

Treatment Approach for Pancreatitis in India

The treatment of pancreatitis in India should follow a stratified approach based on severity, with mild cases managed on general wards and severe cases requiring intensive care unit (ICU) or high dependency unit (HDU) management with full monitoring and systems support. 1, 2

Initial Assessment and Severity Stratification

• Severity assessment should be performed within 48 hours of admission using clinical impression, obesity, APACHE II score, C-reactive protein, Glasgow score, or evidence of organ failure 2
• Laboratory markers including hematocrit, blood urea nitrogen, creatinine, and liver function tests should be monitored as indicators of severity 3
• CT severity index can help stratify patients into mild, moderate, or severe categories to guide management decisions 3

Management Based on Severity

Mild Acute Pancreatitis

• Can be managed on general wards with basic monitoring of vital signs (temperature, pulse, blood pressure) and urine output 1, 2
• Requires peripheral intravenous line for fluid administration and possibly a nasogastric tube 2
• Urinary catheters are generally not warranted in mild cases 2
• Routine CT scanning is unnecessary unless there are clinical signs of deterioration 1

Severe Acute Pancreatitis

• Must be managed in an HDU or ICU setting with full monitoring and systems support 4, 1
• Requires peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 4, 1
• Strict asepsis should be observed with invasive monitoring equipment to prevent infection in pancreatic necrosis 4
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 4
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature is required 4, 1
• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast 4, 1

Fluid Resuscitation

• Lactated Ringer's solution is the preferred fluid for resuscitation in acute pancreatitis 1, 5
• Moderate fluid resuscitation is recommended over aggressive resuscitation to avoid fluid overload 6
• Goal-directed fluid therapy should aim to maintain urine output >0.5 ml/kg body weight 1, 3
• The rate of fluid replacement should be monitored by frequent measurement of central venous pressure in appropriate patients 3

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1, 3
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 4, 1
• A multimodal approach to analgesia is recommended, with patient-controlled analgesia (PCA) integrated with every strategy 4, 1
• Epidural analgesia should be considered for patients with severe pain requiring high doses of opioids for an extended period 4, 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 4, 1
• Early enteral feeding should be initiated, even in severe cases 1, 2
• Both gastric and jejunal feeding can be delivered safely 4, 1
• TPN should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 4, 1
• If ileus persists for more than five days, parenteral nutrition will be required 1, 2

Antibiotic Therapy

• Prophylactic antibiotics are not recommended in mild cases of acute pancreatitis 1, 2
• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may be considered 1
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases 4
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1, 2

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, or a dilated common bile duct 4, 1
• The procedure is best carried out within the first 72 hours after the onset of pain 1, 3
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 4, 1
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission 2

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate 1
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1, 2
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1
• Each case should be managed by a multidisciplinary specialist pancreatic team 1, 2

Common Pitfalls to Avoid

• Delaying drainage of infected collections, which can lead to sepsis and increased mortality 2
• Using prophylactic antibiotics routinely in mild cases 1, 2
• Delaying enteral nutrition unnecessarily 1, 2
• Aggressive fluid resuscitation, which can lead to fluid overload without improving clinical outcomes 6
• Using hydroxyethyl starch (HES) fluids in resuscitation 3
• Relying on specific pharmacological treatments - there is no proven specific drug therapy for acute pancreatitis 4, 3