What is the treatment for pancreatitis?

Treatment of Pancreatitis

Severity-Based Management Approach

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support, while mild cases can be managed on a general ward. 1, 2, 3

Mild Pancreatitis (80% of cases)

• Manage on general ward with basic vital sign monitoring 2, 3
• Peripheral venous access for fluid administration 4
• Continuous oxygen saturation monitoring with supplemental oxygen to maintain >95% 3, 4

Severe Pancreatitis (20% of cases, 95% of deaths)

• Requires peripheral venous access, central venous line for CVP monitoring, urinary catheter, and nasogastric tube 1, 4
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1, 4
• Regular arterial blood gas analysis to detect hypoxia and acidosis 1
• Swan-Ganz catheter if cardiocirculatory compromise exists or initial resuscitation fails 1

Fluid Resuscitation

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive fluid resuscitation. 2, 3

• Lactated Ringer's solution is superior to normal saline for reducing SIRS in the first 24 hours 5
• Target urine output >0.5 ml/kg body weight 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 2
• Early aggressive hydration hastens clinical improvement in mild acute pancreatitis 6

Nutritional Management

Initiate oral feeding immediately rather than keeping patients NPO—this represents a major shift from historical practice. 2

• Regular diet can be advanced as tolerated with appropriate pain management 3
• If oral feeding is not tolerated, use enteral nutrition via nasogastric or nasoenteral tube rather than total parenteral nutrition 2, 3
• Nasogastric feeding is effective in 80% of cases and is as safe as jejunal feeding 2, 3
• Enteral nutrition reduces morbidity compared to parenteral nutrition 7

Pain Management

Pain control is a clinical priority with Dilaudid preferred over morphine or fentanyl in non-intubated patients. 2

• Consider epidural analgesia as an alternative or adjunct in a multimodal approach for severe cases 2
• Pain management should be individualized based on degree of pain and severity of pancreatitis 8

Antibiotic Therapy

Do not use prophylactic antibiotics in mild acute pancreatitis or biliary pancreatitis. 2, 3, 4

• In severe acute pancreatitis with evidence of pancreatic necrosis (>30%), prophylactic antibiotics may reduce complications and deaths 2
• Intravenous cefuroxime is a reasonable balance between efficacy and cost if antibiotics are used 1
• If antibiotic prophylaxis is used, give for a maximum of 14 days 3
• ERCP should always be performed under antibiotic cover 1, 4

Imaging

Dynamic contrast-enhanced CT should be obtained within 3-10 days in severe cases to identify pancreatic necrosis. 2, 4

• Use non-ionic contrast in all cases 1
• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 2, 3, 4
• Follow-up CT scans are recommended only if clinical status deteriorates or fails to show continued improvement 4

Gallstone Pancreatitis Management

Urgent therapeutic ERCP should be performed within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 1, 3, 4

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 1, 4
• Do not perform ERCP in the absence of cholangitis—this is a key recommendation 2
• Perform cholecystectomy during the initial admission unless a clear plan exists for treatment within two weeks 2, 3

Management of Pancreatic Necrosis

All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 7-14 days after onset. 1, 3

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2, 3
• Infected necrosis carries 40% mortality 2

Common Pitfalls to Avoid

• Routine use of antibiotics in mild pancreatitis 3, 4
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 3, 4
• Failing to provide adequate nutritional support 3, 4
• Overuse of CT scanning in mild cases with clinical improvement 3, 4
• Using aggressive fluid resuscitation instead of goal-directed moderate resuscitation 2, 3
• Keeping patients NPO when they can tolerate oral feeding 2