What is the treatment approach for pancreatitis?

Treatment of Pancreatitis

The treatment of acute pancreatitis centers on goal-directed fluid resuscitation, early oral feeding (not NPO), enteral nutrition if oral feeding fails, and avoiding prophylactic antibiotics in mild cases, with specific management based on etiology and severity. 1

Initial Management and Severity Stratification

Mild pancreatitis (80% of cases) can be managed on a general ward with basic vital sign monitoring, while severe pancreatitis (20% of cases, 95% of deaths) requires high dependency unit or intensive care unit admission with full monitoring and systems support. 2, 3

Fluid Resuscitation

• Use goal-directed (moderate) fluid resuscitation rather than aggressive fluid resuscitation to prevent systemic complications. 1, 3
• Ringer's lactate is preferred over normal saline. 4
• Target urine output >0.5 ml/kg body weight. 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion. 2

Common pitfall: Aggressive fluid resuscitation has fallen out of favor; moderate resuscitation is now preferred to avoid fluid overload complications. 3, 4

Nutritional Management

Initiate oral feeding immediately rather than keeping patients NPO—this represents a major shift from historical practice. 1

• A normal "on-demand" diet advanced as tolerated has positive effects on recovery and reduces hospital length of stay. 4
• If oral feeding is not tolerated, use enteral nutrition via nasogastric or nasoenteral tube rather than total parenteral nutrition (TPN). 1, 2
• Nasogastric feeding is effective in 80% of cases and is as safe as jejunal feeding. 2, 3
• TPN should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated. 2
• If ileus persists beyond five days, parenteral nutrition will be required. 2

Pain Management

• Pain control is a clinical priority. 2
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients. 2
• Consider epidural analgesia as an alternative or adjunct in a multimodal approach. 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy. 2
• NSAIDs should be avoided in acute kidney injury. 2

Antibiotic Therapy

Do not use prophylactic antibiotics in mild acute pancreatitis or biliary pancreatitis. 1, 2, 5

• In severe acute pancreatitis with evidence of pancreatic necrosis (>30%), prophylactic antibiotics may reduce complications and deaths. 2
• Intravenous cefuroxime provides a reasonable balance between efficacy and cost for prophylaxis in severe cases. 2
• If prophylaxis is used, limit duration to maximum 14 days. 3
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula-related). 2
• Procalcitonin may help limit unwarranted antibiotic use. 4

Common pitfall: Routine antibiotic use in mild pancreatitis provides no benefit and should be avoided. 3, 5

Etiology-Specific Management

Biliary Pancreatitis

• Perform cholecystectomy during the initial admission unless a clear plan exists for treatment within two weeks. 1, 3
• Do not perform ERCP in the absence of cholangitis—this is a key recommendation. 1
• Urgent therapeutic ERCP is indicated if severe pancreatitis is accompanied by cholangitis, jaundice, or dilated common bile duct. 2, 3
• ERCP should be performed within the first 72 hours after pain onset. 2, 3
• All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found. 2

Common pitfall: Delaying ERCP in severe gallstone pancreatitis with cholangitis increases morbidity. 3, 5

Alcoholic Pancreatitis

• Perform alcohol counseling during the initial admission. 1
• Advise discontinuation of both alcohol and smoking. 6

Imaging

• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 2, 3, 5
• Dynamic contrast-enhanced CT should be obtained in severe cases within 3-10 days to identify pancreatic necrosis. 2, 5
• Follow-up CT is recommended only if clinical status deteriorates or fails to show continued improvement. 2, 5

Common pitfall: Overuse of CT scanning in mild cases with clinical improvement wastes resources and exposes patients to unnecessary radiation. 3

Management of Complications

Pancreatic Necrosis

• All patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided fine needle aspiration if infection is suspected. 3
• Delay drainage as much as possible—this is associated with fewer procedures. 4
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone. 4
• When intervention is required, minimally invasive approaches (percutaneous, endoscopic with lumen-apposing metal stents, or laparoscopic) should be considered before open surgical necrosectomy. 2, 4
• Infected necrosis carries 40% mortality and requires complete debridement of all cavities containing necrotic material. 2, 3

Monitoring Requirements

Severe Cases

• Peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube placement. 2, 5
• Hourly vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature. 2
• Maintain oxygen saturation >95% with supplemental oxygen. 3, 5
• Regular arterial blood gas analysis. 5

Pharmacological Treatment

No specific pharmacological treatment has proven effective beyond organ support and nutrition. 2

• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit despite extensive research. 2

Multidisciplinary Care

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