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

Management of Mild Acute Pancreatitis

• Patients can be managed on general wards with basic monitoring of vital signs and urine output 1
• Management includes peripheral intravenous line for fluid administration and possibly a nasogastric tube 3
• Antibiotics should not be administered routinely in mild cases as there is no evidence they improve outcomes or reduce septic complications 3, 1
• Routine CT scanning is unnecessary unless there are clinical signs of deterioration 3

Management of Severe Acute Pancreatitis

• All patients with severe acute pancreatitis should be managed in an ICU or HDU 3, 4
• Required monitoring includes peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 3
• Strict asepsis should be maintained with invasive monitoring equipment to prevent infection in pancreatic necrosis 3
• Regular arterial blood gas analysis is essential to detect hypoxia and acidosis 4
• When cardiocirculatory compromise exists, a Swan-Ganz catheter may be required for measurement of pulmonary artery wedge pressure, cardiac output, and systemic resistance 3

Fluid Resuscitation

• Aggressive fluid resuscitation is crucial in preventing systemic complications and should be initiated promptly 2
• Lactated Ringer's solution is superior to normal saline in reducing systemic inflammatory response syndrome (SIRS) in the first 24 hours 5, 6
• Goal-directed fluid resuscitation should aim to maintain urine output >0.5 ml/kg body weight 1, 2
• Moderate fluid resuscitation is preferred over aggressive hydration to avoid complications such as fluid overload and respiratory failure 6, 7

Pain Management

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

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 4, 1
• 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 3, 1
• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths 1, 2
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases 3
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 3, 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, 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 1, 8

Management of Complications

• Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require CT scanning 1
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 1, 2
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1
• Minimally invasive approaches for debridement of infected necrosis should be considered before open surgical necrosectomy 2, 8

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 2, 8