What are the key aspects of managing pancreatitis?

Management of Acute Pancreatitis: Key Principles

Aggressive early fluid resuscitation and oxygen supplementation within the first 12-24 hours are the most critical interventions to prevent organ failure and reduce mortality in acute pancreatitis. 1, 2

Diagnosis

Diagnose acute pancreatitis when two of three criteria are present:

• Upper abdominal pain with epigastric or diffuse tenderness 1
• Serum amylase ≥4 times normal OR lipase ≥2 times upper limit of normal 1
• Characteristic imaging findings 1

Critical differential diagnoses to exclude immediately:

• Mesenteric ischemia 1
• Visceral perforation 1
• Leaking abdominal aortic aneurysm 1

Clinical signs to assess:

• Cullen's sign (periumbilical ecchymosis) 1
• Grey-Turner's sign (flank ecchymosis) 1

Severity Assessment and Mortality

Perform severity stratification within 48 hours of admission using clinical impression, APACHE II score, C-reactive protein, or Glasgow score. 3

Expected mortality benchmarks:

• Overall mortality should be <10% 1
• Severe disease mortality should be <30% 1

Mortality patterns:

• One-third of deaths occur in the first week from multiple organ failure 1
• Two-thirds of deaths occur after the first week from infected necrosis 1

Necrotizing pancreatitis mortality:

• Sterile necrosis: 0-11% mortality 1
• Infected necrosis: 40% mortality (can exceed 70%) 1
• Overall necrotizing pancreatitis: 30-40% mortality 1

Initial Resuscitation (First 12-24 Hours)

Oxygen therapy:

• Measure oxygen saturation continuously 1
• Administer supplemental oxygen to maintain arterial saturation >95% 1

Fluid resuscitation protocol:

• Give intravenous crystalloid or colloid aggressively 1
• Target urine output >0.5 ml/kg body weight 1, 2
• Monitor central venous pressure frequently to guide fluid rate 1
• Treat every patient aggressively until severity is established 1

The rationale: Early aggressive fluid replacement and close monitoring have reduced early phase deaths from organ failure compared to previous decades. 1

Location of Care

Mild pancreatitis:

• Manage on general wards with basic monitoring 3
• Peripheral IV line for fluids 3
• Possibly nasogastric tube 3
• Urinary catheter generally not needed 3

Severe pancreatitis - ALL patients require HDU/ICU: 1, 2, 3

• Peripheral venous access 1, 2, 3
• Central venous line for fluid administration and CVP monitoring 1, 2, 3
• Urinary catheter 1, 2, 3
• Nasogastric tube 1, 2, 3
• Hourly monitoring: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature 1, 2
• Regular arterial blood gas analysis to detect hypoxia and acidosis 1, 3

When cardiocirculatory compromise exists or initial resuscitation fails:

• Swan-Ganz catheter for pulmonary artery wedge pressure, cardiac output, and systemic resistance measurement 1

Critical caveat: Maintain strict asepsis with all invasive monitoring equipment, as these serve as potential sources of subsequent sepsis in pancreatic necrosis. 1, 3

Pain Management

Preferred analgesic regimen:

• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 2, 4, 3
• Use multimodal approach 2, 4
• Consider epidural analgesia as alternative or adjunct to IV analgesia 2, 3
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 2

Avoid NSAIDs in acute kidney injury 2

Nutritional Support

Enteral nutrition is superior to parenteral nutrition and prevents gut failure and infectious complications. 1, 2, 4, 3

Feeding protocol:

• Initiate early enteral feeding, even in severe cases 2, 3
• Both gastric (nasogastric) and jejunal (nasojejunal) feeding routes are safe 2, 3
• In mild pancreatitis, start oral feeding immediately if no nausea/vomiting 2

When to use parenteral nutrition:

• Avoid TPN as primary strategy 2, 4, 3
• If ileus persists >5 days, parenteral nutrition is required 2, 3
• Partial parenteral nutrition can be integrated if enteral route not completely tolerated 2

Antibiotic Therapy

The evidence on prophylactic antibiotics is conflicting. 1, 3

Mild pancreatitis:

• Do NOT give prophylactic antibiotics 2, 4, 3

Severe pancreatitis with pancreatic necrosis:

• Prophylactic antibiotics may reduce complications and deaths 1, 2
• If used, intravenous cefuroxime provides reasonable balance between efficacy and cost 1
• Maximum duration: 14 days 3

Definite indications for antibiotics:

• Chest infections 1, 2, 3
• Urinary tract infections 1, 2, 3
• Biliary infections 1, 2, 3
• Catheter-related infections 1, 2, 3

CT Imaging

Timing and indications:

• Routine CT unnecessary in mild cases unless clinical deterioration 1, 2
• Dynamic CT with IV contrast should be obtained within 3-10 days in severe cases 1, 2, 4

CT protocol:

• Use non-ionic contrast in all cases 1, 4
• 100 ml bolus IV injection at 3 ml/s using power injector 1
• Thin collimation (≤5 mm) through pancreatic bed 1
• Images at 40 seconds after injection start 1
• Second series at 65 seconds (portal venous phase) for vein patency 1

CT severity index scoring: 1

CT Grade:

• Normal pancreas: 0
• Pancreatic enlargement: 1
• Inflammation plus mild extrapancreatic changes: 2
• Severe extrapancreatic changes including one fluid collection: 3
• Multiple or extensive extrapancreatic collections: 4

Necrosis score:

• None: 0
• One-third: 2
• One-third to one-half: 4
• Half or more: 6

CT severity index = CT grade + necrosis score

Complications by severity index:

• 0-3: 8% complications, 3% mortality
• 4-6: 35% complications, 6% mortality
• 7-10: 92% complications, 17% mortality

Follow-up CT:

• CT severity index 0-2: Further CT only if clinical status changes 1
• CT severity index 3-10: Additional scans only if deterioration or failure to improve 1
• Consider single scan before discharge in apparently uncomplicated recovery to detect asymptomatic pseudocyst or arterial pseudoaneurysm 1

Critical caveat: CT without IV contrast enhancement gives suboptimal information and should be avoided. 1

Gallstone Pancreatitis Management

Urgent ERCP indications (within 24-72 hours): 1, 2, 4, 3

• Severe gallstone pancreatitis with cholangitis 1, 2, 4, 3
• Jaundice 1, 2, 4, 3
• Dilated common bile duct 1, 2, 4, 3
• Failure to improve within 48 hours despite intensive resuscitation 1

ERCP protocol:

• Always perform under antibiotic cover 1
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1, 3

Definitive management:

• All patients with biliary pancreatitis should undergo cholecystectomy during same hospital admission 3
• Alternative: Clear plan for definitive treatment within 2 weeks 3
• Ideally, laparoscopic cholecystectomy within 2-4 weeks for mild gallstone pancreatitis 1

Management of Infected Necrosis

Infected necrosis is the most serious local complication with 40% mortality. 2

Step-up approach: 4

• Start with percutaneous or endoscopic drainage 4
• This resolves infection in 25-60% without further intervention 4

If drainage fails:

• Consider minimally invasive surgical strategies 4
• Transgastric endoscopic necrosectomy 4
• Video-assisted retroperitoneal debridement (VARD) 4

Timing of intervention:

• Delay surgical, radiologic, or endoscopic drainage for 4 weeks when possible to allow wall formation around necrosis 4
• Postponing surgical interventions >4 weeks after disease onset results in less mortality 4

Indications for early surgical intervention:

• Abdominal compartment syndrome unresponsive to conservative management 4
• Acute ongoing bleeding when endovascular approach unsuccessful 4

Specific Drug Therapy

There is no proven specific pharmacological treatment for acute pancreatitis. 1, 2

Failed therapies despite initial promise:

• Antiproteases (gabexate) 1, 2
• Antisecretory agents (octreotide) 1, 2
• Anti-inflammatory agents (lexipafant) 1, 2

Organizational Requirements

Every hospital receiving acute admissions should have:

• Single nominated clinical team to manage all acute pancreatitis patients 2, 3
• Facilities and expertise for 24-hour ERCP with sphincterotomy and stone extraction/stenting 1

Referral to specialist unit necessary for: 2, 3

• Extensive necrotizing pancreatitis (>30% necrosis) 2, 3
• Other complications requiring multidisciplinary specialist pancreatic team 2, 3

Common Pitfalls to Avoid

• Delaying fluid resuscitation - must be aggressive in first 12-24 hours 1, 2
• Using CT without IV contrast - provides suboptimal information 1
• Routine prophylactic antibiotics in mild cases - no benefit 2, 4, 3
• Using TPN as primary nutritional support - enteral nutrition superior 2, 4, 3
• Early surgical intervention for infected necrosis - delay when possible 4
• Poor asepsis with invasive lines - increases sepsis risk in necrosis 1, 3
• Delaying drainage of infected collections - leads to sepsis and increased mortality 3