What is the management of acute pancreatitis?

Management of Acute Pancreatitis

Initial Assessment and Resuscitation

All patients with severe acute pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support. 1, 2

Immediate Monitoring Requirements

• Establish hourly vital sign assessment: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 2
• Place peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube in severe cases 2
• Perform regular arterial blood gas analysis to detect hypoxia and acidosis 3

Aggressive Fluid Resuscitation

• Initiate aggressive intravenous fluid resuscitation immediately upon presentation - this is crucial in preventing systemic complications and should be started within the first 12-24 hours for maximum benefit 2, 4
• Target urine output >0.5 ml/kg body weight 2, 5
• Use Lactated Ringer's solution preferentially over normal saline 5
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate regularly to assess adequate tissue perfusion 2
• Avoid hydroxyethyl starch (HES) fluids as they increase the risk of multiple organ failure 5

Pain Management

Pain control is a clinical priority and should be addressed aggressively. 2

• Use Dilaudid preferentially over morphine or fentanyl in non-intubated patients 2, 5
• Implement patient-controlled analgesia (PCA) as part of every pain management strategy 2
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 2, 5
• Avoid NSAIDs in patients with acute kidney injury 2

Nutritional Support

If nutritional support is required, the enteral route should be used if tolerated - this is superior to total parenteral nutrition (TPN) in preventing gut failure and infectious complications. 1, 2, 5

Enteral Nutrition Protocol

• Initiate early enteral nutrition, even in severe cases, preferably within 24 hours after initial resuscitation 2, 4, 6
• Both gastric (nasogastric) and jejunal (nasojejunal) feeding routes are acceptable and can be delivered safely 2, 6
• The nasogastric route is effective in 80% of cases 1
• In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 4

Parenteral Nutrition

• Avoid TPN as the primary nutritional support strategy 2, 5, 4
• Consider partial parenteral nutrition integration only if the enteral route is not completely tolerated 2
• If ileus persists for more than five days, parenteral nutrition will be required 2

Antibiotic Therapy

Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection. 2, 5, 4

When to Use Antibiotics

• Do not use prophylactic antibiotics in mild cases of acute pancreatitis 2, 5
• In severe acute pancreatitis with evidence of pancreatic necrosis, the evidence is conflicting - some trials show benefit, others do not, and there is no consensus 1
• If antibiotic prophylaxis is used in severe cases, limit duration to a maximum of 14 days 1
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost for prophylaxis in severe cases 2
• Administer antibiotics when specific infections occur (respiratory, urinary tract, biliary, or catheter-related) 2, 5
• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, decreasing morbidity and mortality 4

Management of Biliary Causes

Urgent therapeutic ERCP should be performed within 72 hours 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, 5, 4

ERCP Protocol

• Perform ERCP within the first 72 hours after 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
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 1
• Use pancreatic duct stents and/or postprocedure rectal NSAID suppositories to lower the risk of severe post-ERCP pancreatitis in high-risk patients 4

Definitive Biliary Management

• 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
• Cholecystectomy should not be delayed more than two weeks after discharge from hospital 1

Imaging

Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration. 2

• Reserve contrast-enhanced CT and/or MRI for patients in whom the diagnosis is unclear or who fail to improve clinically 4
• Obtain dynamic CT scanning in severe cases within 3-10 days of admission to identify pancreatic necrosis and guide management 2, 5
• Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require computed tomography 1
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement 2
• Consider MRCP or endoscopic ultrasound to screen for occult common bile duct stones in patients with unknown etiology 5

Management of Pancreatic Necrosis and Infected Necrosis

Asymptomatic pancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension. 4

Assessment of Necrosis

• All patients with persistent symptoms and greater than 30% pancreatic necrosis should undergo image-guided fine needle aspiration to obtain cultures 1
• Patients with smaller areas of necrosis and clinical suspicion of sepsis also require aspiration 1
• The presence of >30% necrosis is a useful marker of the most severe cases and should prompt discussion with or referral to a specialist unit 1

Management of Infected Necrosis

• In stable patients with infected necrosis, intervention should be delayed preferably for 4 weeks to allow development of a wall around the necrosis. 4, 5
• Use a step-up approach: start with percutaneous or endoscopic drainage, which may resolve infection in 25-60% of patients without further intervention 5
• If drainage fails, consider minimally invasive surgical strategies such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD) before open surgical necrosectomy 5
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 1
• Postponing surgical interventions for more than 4 weeks after disease onset results in less mortality 5

Indications for Early Surgical Intervention

• Abdominal compartment syndrome unresponsive to conservative management 5
• Acute ongoing bleeding when endovascular approach is unsuccessful 5

Specialist Care and Referral

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 1, 2

When to Refer to Specialist Unit

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications who may require ICU care, or interventional radiological, endoscopic, or surgical procedures 1, 2
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team including specialists in surgery, endoscopy, intensive care, anesthesia, gastroenterology, and nutrition 1, 2, 5

Severity Assessment

• Assess hemodynamic status immediately upon presentation and begin resuscitative measures as needed 4
• Patients with organ failure and/or systemic inflammatory response syndrome (SIRS) should be admitted to an ICU or intermediary care setting 4
• Severity stratification should be made in all patients within 48 hours of diagnosis 1
• Repeat severity assessment at least within 48 hours following diagnosis, as disease condition changes every moment 7

Common Pitfalls to Avoid

• Do not withhold pain medication - no evidence supports restrictions in pain control 2
• Do not use routine prophylactic antibiotics in mild cases or sterile necrosis 2, 5, 4
• Do not use TPN as first-line nutritional support 2, 5, 4
• Do not perform early surgical intervention when it can be delayed - wait at least 4 weeks when possible 5, 4
• Do not use hydroxyethyl starch fluids 5
• Do not delay ERCP beyond 72 hours in patients with cholangitis or severe gallstone pancreatitis 1, 2