What is the treatment approach for pancreatitis?

Treatment Approach for Pancreatitis

The treatment of pancreatitis should be stratified based on severity, with mild cases managed on general wards with basic monitoring and severe cases requiring intensive care with full monitoring and systems support. 1, 2

Initial Assessment and Classification

• Pancreatitis is classified as mild (80% of cases, <5% of deaths) or severe (20% of cases, 95% of deaths) based on objective criteria 3
• Basic monitoring requirements include regular assessment of vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Laboratory assessment should include lipase, C-reactive protein, and other markers to determine severity 3
• Patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission require contrast-enhanced CT imaging 3

Management of Mild Acute Pancreatitis

• Patients can be managed on general wards with monitoring of vital signs 3
• Oxygen saturation should be continuously monitored with supplemental oxygen to maintain arterial saturation >95% 3
• Moderate fluid resuscitation is preferred over aggressive resuscitation, as aggressive fluid therapy is associated with higher mortality 4
• Antibiotics should not be administered routinely in mild cases 5, 3
• Regular diet can be advanced as tolerated with appropriate pain management 3
• Routine CT scanning is unnecessary unless clinical deterioration occurs 3

Management of Severe Acute Pancreatitis

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive care unit 1, 2
• Required monitoring includes peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 1
• Goal-directed fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1
• 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
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia 1
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

Nutritional Support

• Enteral nutrition is recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications 5, 1
• Early enteral feeding should be initiated, even in severe cases 1
• Both gastric and jejunal feeding can be delivered safely 1
• For patients who are intolerant of oral feeding, use enteral (via either NG or nasoenteral tube) rather than parenteral nutrition 5
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

• Prophylactic antibiotics are not recommended in mild cases of acute pancreatitis 5, 1
• In severe acute pancreatitis with evidence of pancreatic necrosis, the evidence regarding antibiotic prophylaxis is conflicting 3, 2
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 3
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 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, or a dilated common bile duct 1, 3
• 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 1
• For patients with biliary pancreatitis, cholecystectomy should be performed during initial admission 5
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for treatment within two weeks 3

Management of Complications

• Infected necrosis is the most serious local complication with a high mortality rate 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 Considerations

• For patients with alcoholic pancreatitis, perform alcohol counseling during initial admission 5
• No specific pharmacological treatment except for organ support and nutrition has proven effective 1
• 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 or with other complications 1

Common Pitfalls to Avoid

• Using aggressive fluid resuscitation, which has been associated with higher mortality compared to moderate fluid replacement 4
• Routine use of antibiotics in mild pancreatitis 3
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 3
• Failing to provide adequate nutritional support 3
• Overuse of CT scanning in mild cases with clinical improvement 3