What is the approach to managing acute 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 (ICU) or high dependency unit (HDU) care with full monitoring and systems support. 1, 2

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, Glasgow score, or persisting organ failure 2
• Basic monitoring requirements include regular assessment of vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• The etiology of acute pancreatitis should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic" 2

Fluid Resuscitation

• Aggressive fluid resuscitation is crucial in preventing systemic complications and should be initiated promptly 1
• Lactated Ringer's solution is preferred over normal saline as it reduces severity, mortality, need for intensive care, and both systemic and local complications 3
• Goal-directed fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1, 2
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion 1

Pain Management

• Pain control is a clinical priority in acute pancreatitis 1, 2
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1, 2
• A multimodal approach including epidural analgesia should be considered for moderate to severe pain 2
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition to prevent gut failure and infectious complications 1, 2
• Early enteral feeding should be initiated, even in severe cases 1, 2
• Both gastric and jejunal feeding can be delivered safely 1, 2
• 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 reduce complications and deaths, though evidence is conflicting 1, 2
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 2
• 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 1, 2
• The procedure is best carried out within the first 72 hours after the onset of pain 1, 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1, 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

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 in severe cases 4, 1

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 4, 1
• Surgical debridement may be necessary for infected necrosis 1
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 1
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1

Specific Pharmacological Treatment

• No specific pharmacological treatment except for organ support and nutrition has proven effective 1, 4
• Despite initial encouraging results, antiproteases such as gabexate, antisecretory agents such as octreotide, and anti-inflammatory agents have not shown benefit in large randomized studies 4, 1
• Octreotide use may be associated with biliary complications including gallstones, ascending cholangitis, and pancreatitis 5

Specialist Care

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

Common Pitfalls to Avoid

• Delaying fluid resuscitation, which can lead to increased morbidity and mortality 6, 7
• Using normal saline instead of lactated Ringer's solution for fluid resuscitation 8, 3
• Delaying enteral nutrition unnecessarily, which can lead to gut failure and infectious complications 1, 2
• Using prophylactic antibiotics routinely in mild cases without evidence of necrosis 1, 2
• Delaying ERCP in patients with severe gallstone pancreatitis and cholangitis 1, 2
• Failing to monitor patients closely for development of organ failure and local complications 1, 2