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 the single most critical intervention to prevent systemic complications 2, 4
• Target urine output >0.5 ml/kg body weight 2, 4
• Lactated Ringer's solution is preferred over normal saline 5
• Early aggressive hydration is most beneficial within the first 12-24 hours and may have little benefit beyond this window 4
• 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

Dilaudid is the preferred opioid over morphine or fentanyl in non-intubated patients. 2, 5

• Pain control is a clinical priority and no evidence supports restrictions in pain medication 2
• Avoid NSAIDs in patients with acute kidney injury 2
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 2, 5

Nutritional Support

If nutritional support is required, the enteral route should be used if tolerated - this prevents gut failure and infectious complications. 1, 2

Mild Pancreatitis

• Oral feedings can be started immediately if there is no nausea and vomiting 4
• Use a low-fat oral diet 6

Severe Pancreatitis

• Initiate early enteral nutrition within 24 hours after admission, following initial volume resuscitation and control of nausea and pain 2, 6
• Both nasogastric and nasojejunal feeding routes are acceptable and equally safe 1, 2, 6
• The nasogastric route is effective in 80% of cases 1
• Avoid total parenteral nutrition (TPN) as the primary nutritional support strategy 2, 5, 4
• If ileus persists for more than five days, parenteral nutrition will be required 2
• Partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 2

Antibiotic Therapy

Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection. 1, 2, 5

When to Use Antibiotics

• Administer antibiotics only when specific infections occur: respiratory, urinary tract, biliary, or catheter-related 2, 5
• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths, though evidence is conflicting 1, 2
• If antibiotic prophylaxis is used, limit duration to a maximum of 14 days 1
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases 2
• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, decreasing morbidity and mortality 4

Management of Biliary Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with gallstone pancreatitis who have severe disease, cholangitis, jaundice, or a dilated common bile duct. 1, 2, 5

ERCP Indications and Timing

• Perform ERCP within 24 hours in patients with acute pancreatitis and concurrent acute cholangitis 4
• Best carried out 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

Definitive Treatment

• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan exists for treatment within two weeks 1
• Cholecystectomy should not be delayed more than two weeks after discharge to avoid risk of recurrent potentially severe pancreatitis 1

Imaging

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

• Reserve contrast-enhanced CT (CECT) 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 to identify pancreatic necrosis and guide management 2
• Patients with persisting organ failure, signs of sepsis, or deterioration 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
• Use dynamic helical or multislice CT with non-ionic contrast 5

Management of Pancreatic Necrosis

In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow development of a wall around the necrosis. 4

Assessment of Necrosis

• All patients with persistent symptoms and greater than 30% pancreatic necrosis should undergo image-guided fine needle aspiration 1
• Patients with smaller areas of necrosis and clinical suspicion of sepsis also require aspiration 1
• 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

Infected Necrosis Management

• Infected necrosis has a mortality rate of 40% 2
• 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

Asymptomatic Collections

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

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 requiring ICU care, or interventional radiological, endoscopic, or surgical procedures 1, 2
• Each case should be managed by a multidisciplinary specialist pancreatic team including specialists in surgery, endoscopy, intensive care, anesthesia, gastroenterology, and nutrition 1, 2, 5

Severity Assessment

• Assess severity in all patients within 48 hours of diagnosis 1
• Severity assessment should be conducted repeatedly at least within 48 hours following diagnosis, as disease condition changes every moment 7
• Patients with organ failure and/or systemic inflammatory response syndrome (SIRS) should be admitted to an ICU or intermediary care setting 4

Pharmacological Treatment

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

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