What is the treatment for acute pancreatitis?

Acute Pancreatitis: Comprehensive Management

Initial Assessment and Diagnosis

Acute pancreatitis is diagnosed based on typical abdominal pain, elevated lipase (amylase no longer essential), or characteristic imaging findings. 1

• Classification: 80% of cases are mild (<5% mortality), while 20% are severe (95% of deaths) 2
• Laboratory assessment: Check lipase, white blood cell count, C-reactive protein, and procalcitonin (PCT is most sensitive for detecting pancreatic infection) 2
• Imaging: Ultrasound is mandatory at admission to detect gallstones or bile duct stones 2, 3
• Severity stratification: Must be performed within 48 hours of diagnosis and repeated, as clinical status can deteriorate rapidly 2, 4

Management of Mild Acute Pancreatitis

Patients with mild pancreatitis can be managed on general wards with conservative treatment consisting of fluid replacement, pain control, and early feeding. 2, 5

• Monitoring: Basic vital signs on general ward suffice 2
• Fluid resuscitation: Administer via peripheral IV access with goal-directed balanced crystalloids (lactated Ringer's preferred over normal saline) 2, 6
• Pain control: Opioids are first-line and superior to NSAIDs 1
• Nutrition: Advance regular diet as tolerated with oral pain medications 2
• Antibiotics: Do NOT administer routinely - no evidence of benefit in mild cases 2
• Imaging: Routine CT scanning is unnecessary unless clinical deterioration occurs 2

Management of Severe Acute Pancreatitis

All patients with severe acute pancreatitis must be managed in an HDU or ICU setting with full monitoring and multidisciplinary intensive care. 7, 2

Initial Resuscitation and Monitoring

• Vascular access: Establish peripheral venous access AND central venous line for fluid administration and CVP monitoring 7, 2
• Monitoring equipment: Place urinary catheter, nasogastric tube, and consider Swan-Ganz catheter if initial resuscitation fails 7
• Vital signs: Monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature with accurate charting 7
• Arterial blood gases: Regular analysis is essential as hypoxia and acidosis may be detected late clinically 7
• Oxygen therapy: Maintain arterial saturation >95% with supplemental oxygen 2

Fluid Resuscitation Strategy

Goal-directed moderate fluid resuscitation with balanced crystalloids (lactated Ringer's) is superior to aggressive hydration with normal saline. 6, 1

• Rate: Avoid excessive fluids >3mL/kg/h 1
• Monitoring: Adjust dose while constantly assessing circulatory dynamics 4
• Avoid: Do NOT use hydroxyethyl starch (HES) 3
• Goal: Optimize tissue perfusion while avoiding fluid overload, especially in patients at risk for ARDS 3

Nutritional Support

Early enteral nutrition (within 24 hours) via oral, nasogastric, or nasojejunal route is strongly preferred over parenteral nutrition. 2, 1

• Route: Nasogastric feeding is effective in 80% of cases and can be used safely 7, 2, 3
• Timing: Begin within first 24 hours to reduce risk of infected necrosis 3, 1
• Parenteral nutrition: Only if enteral route cannot be tolerated after 5 days; total parenteral nutrition should be avoided 7, 3
• Caution: Use caution with nasogastric feeding in patients with impaired consciousness due to aspiration risk 7

Antibiotic Use

Routine prophylactic antibiotics are no longer recommended for all patients with acute pancreatitis, even in necrotizing cases. 2, 3, 1

• Severe cases: May consider prophylactic antibiotics to prevent local and septic complications 7, 2
• Agent selection: If used, intravenous cefuroxime provides reasonable balance between efficacy and cost 7
• Infected necrosis: Antibiotics should only be administered when specific infections occur (respiratory, urinary, biliary, catheter-related) 3
• Timing consideration: Infected necrosis is rare in first 2 weeks 1
• Procalcitonin guidance: May support therapeutic decisions to distinguish inflammation from infection 6, 1

Imaging in Severe Cases

Dynamic contrast-enhanced CT with non-ionic contrast should be obtained within 3-10 days of admission, optimally after 7 days. 7, 2, 1

• Delay imaging: Unless necrosis is suspected or diagnosis uncertain; optimal timing is ≥72 hours 1
• Repeat imaging: Only if clinical status deteriorates or fails to show continued improvement 2
• Indications for earlier CT: Persistent symptoms, signs of sepsis, or clinical deterioration 6-10 days after admission 2

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP with sphincterotomy is required for severe gallstone pancreatitis with cholangitis, jaundice, or dilated common bile duct within 72 hours of symptom onset. 7, 8

ERCP Timing and Indications

• Emergency ERCP (<24 hours): Mandatory for cholangitis (fever, rigors, positive blood cultures, deranged liver function) 7, 3, 8
• Urgent ERCP (within 72 hours): For severe gallstone pancreatitis or high suspicion of persistent common bile duct stone 7, 3, 8
• Sphincterotomy: Required whether or not stones are found in the bile duct 7, 8
• Antibiotic coverage: ERCP must always be performed under antibiotic cover 7, 8
• Without cholangitis: Urgent ERCP is not indicated in patients without cholangitis 6, 1

Cholecystectomy Timing

For mild gallstone pancreatitis, perform cholecystectomy during the same hospital admission or within 2 weeks to prevent recurrent potentially fatal attacks. 7, 8

• Mild cases: Laparoscopic cholecystectomy preferred during index admission 8
• Severe cases: Delay cholecystectomy 4-6 weeks until lung injury and systemic disturbance have resolved 8
• Rationale: Significant risk of further severe and life-threatening acute pancreatitis if gallstones not definitively treated 7

Management of Complications

Pancreatic Necrosis

For patients with persistent symptoms and >30% pancreatic necrosis, perform image-guided fine needle aspiration for culture 7-14 days after onset. 2, 8

• Infected necrosis: Complete debridement of all necrotic material is required 7, 8
• Step-up approach: Begin with antibiotics, then drainage, then delayed minimally-invasive necrosectomy 1
• Access route: Endoscopic access is preferred; open surgery is obsolete 1
• Timing: Necrosectomy should be performed as late as possible 9
• Sterile necrosis: Non-surgical treatment is indicated 9

Pancreatic Abscess

Drainage is recommended for pancreatic abscess. 9

Special Populations

Pediatric Considerations

• Fluid resuscitation: Use isotonic crystalloids to optimize tissue perfusion while avoiding fluid overload 3
• Pain control: Multimodal analgesia approach; avoid NSAIDs in patients with acute kidney injury 3
• Early feeding: Within 24 hours via nasogastric route (effective in 80% of cases) 3
• ERCP timing: Urgent (<24h) for cholangitis; early (<72h) for suspected persistent common bile duct stone 3
• Mortality targets: Should be <10% overall and <30% in severe cases 3

Common Pitfalls to Avoid

• Do NOT use routine antibiotics in mild pancreatitis 2
• Do NOT delay ERCP in severe gallstone pancreatitis with cholangitis 2
• Do NOT use aggressive fluid resuscitation (>3mL/kg/h) 1
• Do NOT use hydroxyethyl starch for fluid resuscitation 3
• Do NOT perform routine CT scanning in mild cases 2
• Do NOT delay cholecystectomy in mild gallstone pancreatitis beyond index admission 8
• Do NOT use plasmapheresis in hypertriglyceridemic pancreatitis (no proven benefit) 1
• Do NOT rely on prognostic tools (BISAP, Ranson) or markers (hematocrit, lactate, BUN) alone to predict severe or necrotizing pancreatitis 1

Outcomes and Prognosis

Outcomes improve significantly in specialized, high-volume centers with critical care, interventional endoscopy/radiology, and pancreatic surgery expertise. 1

• Early deaths: Can be reduced through full resuscitation and multidisciplinary approach addressing circulatory, respiratory, and renal failure 7
• Mortality reduction: Increased accuracy in early diagnosis and development of intensive care have significantly decreased mortality in severe pancreatitis 5