What is the management approach for 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 comprehensive monitoring and aggressive early fluid resuscitation. 1

Immediate Monitoring Requirements

• Establish hourly vital sign monitoring: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Place peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube in severe cases 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate regularly to assess tissue perfusion 1

Fluid Resuscitation Strategy

• Begin aggressive intravenous fluid resuscitation immediately upon presentation, targeting urine output >0.5 ml/kg body weight 1, 2
• Lactated Ringer's solution is preferred over normal saline 2
• Early aggressive hydration is most beneficial within the first 12-24 hours and may have little benefit beyond this window 3
• Avoid hydroxyethyl starch (HES) fluids as they increase the risk of multiple organ failure 2

Pain Management

Use Dilaudid as the preferred opioid in non-intubated patients, with a multimodal approach incorporating patient-controlled analgesia. 1

• Avoid morphine or fentanyl as first-line agents in non-intubated patients 1
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia, particularly for patients requiring high-dose opioids for extended periods 1, 4
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1
• Avoid NSAIDs in patients with acute kidney injury 1

Nutritional Support

Initiate early enteral nutrition via nasogastric or nasojejunal tube rather than total parenteral nutrition to prevent gut failure and infectious complications. 1, 4

Mild Pancreatitis

• Start oral feedings immediately if there is no nausea and vomiting 3
• Use a low-fat oral diet 5

Severe Pancreatitis

• Begin enteral nutrition within 24 hours after admission, following initial volume resuscitation and control of nausea and pain 5
• Both gastric (nasogastric) and jejunal (nasojejunal) feeding routes are safe and effective, with nasogastric feeding successful in 80% of cases 6, 1, 4
• Use a semielemental formula with omega-3 fatty acids when available 5
• Avoid total parenteral nutrition as the primary strategy; reserve it only for patients who cannot tolerate enteral nutrition or when enteral feeding is contraindicated 1, 4
• If ileus persists for more than five days, parenteral nutrition will be required 1
• Consider partial parenteral nutrition integration if the enteral route is not completely tolerated 1

Special Consideration for Intra-abdominal Pressure

• If intra-abdominal pressure (IAP) exceeds 15 mmHg, use the nasojejunal route starting at 20 mL/h with rate increases based on tolerance 4
• Temporarily discontinue enteral nutrition and initiate parenteral nutrition when IAP exceeds 20 mmHg or abdominal compartment syndrome develops 4

Antibiotic Therapy

Do not use prophylactic antibiotics routinely in mild acute pancreatitis or sterile necrosis. 1, 3

Evidence Regarding Prophylaxis

The evidence on antibiotic prophylaxis is conflicting. While some trials show benefit with reduced infections and deaths (31/178 vs 51/177 infections, p<0.02; 10/178 vs 26/177 deaths, p<0.01), other trials do not demonstrate benefit 6. The 2013 American College of Gastroenterology guideline does not recommend routine prophylactic antibiotics 3, though earlier UK guidelines suggest prophylaxis may be considered in severe cases with necrosis 6.

Practical Approach

• In severe acute pancreatitis with documented pancreatic necrosis >30%, prophylactic antibiotics may reduce complications and deaths 1
• If antibiotic prophylaxis is used, limit duration to a maximum of 14 days 6, 4
• Intravenous cefuroxime provides a reasonable balance between efficacy and cost for prophylaxis 1
• Administer antibiotics when specific infections occur: respiratory, urinary tract, biliary, or catheter-related 1, 2
• In patients with infected necrosis, use antibiotics that penetrate pancreatic necrosis to potentially delay intervention 3

Imaging

Reserve contrast-enhanced CT for patients with unclear diagnosis, failure to improve clinically, or suspected complications. 3

• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 1
• Obtain dynamic CT scanning within 3-10 days of admission using non-ionic contrast in severe cases to identify pancreatic necrosis 1, 2
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement 1
• Consider magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound to screen for occult common bile duct stones in patients with unknown etiology 2

Management of Biliary Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with suspected or proven gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 6, 1

ERCP Indications and Timing

• Urgent ERCP (within 24 hours) is mandatory for patients with concurrent acute cholangitis 3
• Perform ERCP within the first 72 hours after pain onset for severe gallstone pancreatitis 6
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 6
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 6

Definitive Management of Gallstones

• Perform cholecystectomy during the same hospital admission to prevent recurrence, which may be severe and life-threatening 6
• Do not delay definitive treatment more than two weeks after discharge from hospital 6
• For unfit patients, endoscopic sphincterotomy alone is adequate treatment 6
• Use pancreatic duct stents and/or postprocedure rectal NSAID suppositories to lower the risk of severe post-ERCP pancreatitis in high-risk patients 3

Management of Pancreatic Necrosis and Infected Necrosis

Delay interventions for infected necrosis until at least 4 weeks after disease onset when possible, using a step-up approach starting with percutaneous or endoscopic drainage. 4, 2

Assessment of Necrosis

• Patients with persistent symptoms and greater than 30% pancreatic necrosis should undergo image-guided fine needle aspiration to obtain material for culture 6, 4
• 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 6

Indications for Early Intervention (Cannot Be Delayed)

• Abdominal compartment syndrome unresponsive to conservative management 4, 2
• Acute ongoing bleeding when endovascular approach is unsuccessful 4, 2
• Bowel ischemia or acute necrotizing cholecystitis 4

Step-Up Approach for Infected Necrosis

• Start with percutaneous or endoscopic drainage, which may resolve infection in 25-60% of patients without further intervention 2
• Progress to minimally invasive necrosectomy (transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement) if drainage fails to improve the patient's condition 2
• Consider minimally invasive approaches before open surgical necrosectomy 1
• Complete debridement of all cavities containing necrotic material is required for infected necrosis 6

Post-Necrosectomy Nutrition

• Oral food intake can be initiated within 24 hours after minimally invasive necrosectomy if the patient is hemodynamically stable with controlled septic parameters and adequate gastric emptying 4
• For patients unable to tolerate oral feeding, use enteral nutrition via nasojejunal tube 4

Management of Other Local Complications

Manage pseudocysts and pancreatic abscesses with surgical, endoscopic, or radiological intervention based on individual features and local expertise. 6

• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension 3
• Each case requires individualized management by a multidisciplinary specialist pancreatic team 6, 1

Specialist Referral and Team Structure

Every hospital receiving acute admissions must have a single nominated clinical team to manage all patients with acute pancreatitis. 6

Criteria for Specialist Unit Referral

• Extensive necrotizing pancreatitis (>30% necrosis) 6
• Complications requiring ICU care 6
• Need for interventional radiological, endoscopic, or surgical procedures 6

Specialist Unit Requirements

• Multidisciplinary team including specialists in surgery, endoscopy, intensive care, anesthesia, gastroenterology, and nutrition 6
• Team leader: surgeon or gastroenterologist with specific expertise in pancreaticobiliary disease 6
• HDU/ICU facilities with renal and respiratory support capabilities 6
• Expertise in dynamic helical or multislice CT, percutaneous needle aspiration, and drainage procedures 6
• Emergency ERCP and therapeutic endoscopy capabilities by experienced endoscopist 6

Treatments Without Proven Benefit

No specific pharmacological treatment beyond organ support and nutrition has proven effective for acute pancreatitis. 1

• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit in clinical trials 1
• Despite Japanese consensus recommending large-dose synthetic protease inhibitors, their efficacy remains controversial 7

Common Pitfalls to Avoid

• Do not delay fluid resuscitation; the first 12-24 hours are critical 3
• Do not use total parenteral nutrition as first-line nutritional support 1, 4
• Do not perform early surgical intervention for infected necrosis when it can be safely delayed 4, 2
• Do not use routine prophylactic antibiotics in mild pancreatitis or sterile necrosis 1, 3
• Do not delay cholecystectomy beyond two weeks after discharge in biliary pancreatitis 6
• Do not assume nasogastric feeding will fail; it is effective in 80% of severe cases 6, 1