What is the management approach for pancreatitis?

Management of Acute Pancreatitis

The management of acute pancreatitis requires immediate assessment of severity, with all severe cases requiring admission to an intensive care unit (ICU) or high dependency unit (HDU) with full monitoring and systems support. 1

Initial Assessment and Management

• All patients with severe acute pancreatitis should be managed in an HDU or ICU setting with full monitoring including regular assessment of vital signs, oxygen saturation, urine output, and temperature 1
• Basic monitoring requirements include peripheral venous access, central venous line, urinary catheter, and nasogastric tube in severe cases 1
• Contrast-enhanced CT scanning should be obtained in severe cases to identify pancreatic necrosis but is unnecessary in mild cases unless clinical deterioration occurs 1, 2

Fluid Resuscitation

• Moderate fluid resuscitation is preferred over aggressive fluid resuscitation to prevent fluid overload complications 3, 4
• Fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1
• Ringer's lactate has advantages over normal saline for fluid resuscitation 3
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion 1, 5

Nutritional Support

• Early enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 1, 2
• In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 2
• A normal "on-demand" diet has a positive effect on recovery and length of hospital stay 3
• Both gastric and jejunal feeding can be delivered safely in severe cases 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1
• A multimodal pain management approach including epidural analgesia should be considered to reduce opioid-related side effects 1, 3
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

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 reduce complications and deaths 1
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone, though the optimal choice and duration remains unclear 3

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 1, 2
• The procedure is best carried out 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
• Pancreatic duct stents and/or post-procedure rectal NSAIDs should be used to lower the risk of severe post-ERCP pancreatitis in high-risk patients 2

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate 1
• In stable patients with infected necrosis, drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 1, 2
• 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 2

Special Considerations

• Coagulopathy in pancreatitis should be monitored but does not typically require intervention unless clinically significant bleeding occurs 6
• For elevated INR without bleeding, consider vitamin K supplementation rather than fresh frozen plasma 6
• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 1

Monitoring and Follow-up

• Regular monitoring of vital signs and laboratory parameters is essential 1
• Follow-up imaging is recommended to monitor the resolution of collections in severe cases 1
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1