What is the management approach for pancreatitis?

Management of Acute Pancreatitis

All patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high-dependency unit (HDU) with full monitoring and systems support, while mild cases can be managed on general wards with basic monitoring. 1

Initial Assessment and Severity Stratification

Immediate assessment of hemodynamic status is critical upon presentation, with resuscitative measures begun as needed. 2 Patients with organ failure and/or systemic inflammatory response syndrome (SIRS) require ICU or intermediary care admission. 2

Monitoring Requirements

Severe cases require:

• Peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 1
• Hourly vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1
• Regular arterial blood gas analysis to detect hypoxia and acidosis 3
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1

Mild cases require:

• Basic vital signs monitoring without routine invasive monitoring 4

Fluid Resuscitation

Moderate fluid resuscitation with lactated Ringer's solution is superior to aggressive resuscitation, which increases fluid overload without improving outcomes. 5 The landmark 2022 WATERFALL trial demonstrated that aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) resulted in 20.5% fluid overload versus 6.3% with moderate resuscitation (10 ml/kg bolus in hypovolemic patients or no bolus in normovolemic patients, followed by 1.5 ml/kg/hour), without reducing the incidence of moderately severe or severe pancreatitis. 5

Key principles:

• Initiate fluid resuscitation promptly, as early aggressive hydration is most beneficial within the first 12-24 hours 2
• Target urine output >0.5 ml/kg body weight 1
• Use lactated Ringer's solution as the preferred crystalloid 6
• Reassess at 12,24,48, and 72 hours, adjusting based on clinical status 5
• Elevated hematocrit, blood urea nitrogen, or creatinine should prompt more intensive early resuscitation 7

Pain Management

Implement a multimodal pain management approach with patient-controlled analgesia (PCA) as the foundation. 1

Specific recommendations:

• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia 1, 6
• Integrate PCA with every pain management strategy 1
• Avoid NSAIDs in patients with acute kidney injury 1
• No evidence supports restrictions in pain medication otherwise 1

Nutritional Support

Enteral nutrition is strongly recommended over total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2

Feeding strategy:

• In mild pancreatitis, start oral feedings immediately if no nausea and vomiting are present 2
• In severe pancreatitis, initiate early enteral nutrition even in severe cases 1
• Both gastric and jejunal feeding can be delivered safely 1
• A normal "on-demand" diet has positive effects on recovery and reduces hospital length of stay 6
• Avoid TPN, but consider partial parenteral nutrition integration if enteral route is not completely tolerated 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

Prophylactic antibiotics are not recommended in mild acute pancreatitis. 1, 2

For severe acute pancreatitis with pancreatic necrosis:

• Prophylactic antibiotics may reduce complications and deaths 1
• Intravenous cefuroxime provides a reasonable balance between efficacy and cost for prophylaxis 1
• In infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, decreasing morbidity and mortality 2
• Procalcitonin may be used to limit unwarranted antibiotic use 6
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone, though optimal choice and duration remain unclear 6

Antibiotics are warranted when specific infections occur:

• Chest, urine, bile, or cannula-related infections 1

Management of Gallstone Pancreatitis

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

Specific timing:

• Patients with acute cholangitis require ERCP within 24 hours of admission 2
• ERCP is best performed within the first 72 hours after pain onset 1
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1
• ERCP should always be performed under antibiotic cover 8

Cholecystectomy timing:

• In mild gallstone pancreatitis, perform laparoscopic cholecystectomy within two to four weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 8
• In severe acute pancreatitis, delay cholecystectomy until the inflammatory process has subsided 8

Post-ERCP pancreatitis prevention:

• Use pancreatic duct stents and/or postprocedure rectal NSAID suppositories in high-risk patients 2

Imaging

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 1

Imaging indications:

• Reserve contrast-enhanced CT and/or MRI for patients with unclear diagnosis or failure to improve clinically 2
• Obtain dynamic CT scanning in severe cases to identify pancreatic necrosis and guide management 1
• Follow-up CT is recommended only if clinical status deteriorates or fails to show continued improvement in severe cases 1
• Follow-up imaging to monitor resolution of collections in severe cases 1

Management of Complications

Infected necrosis is the most serious local complication with 40% mortality. 1

Intervention strategy:

• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension 2
• In stable patients with infected necrosis, delay surgical, radiologic, and/or endoscopic drainage preferably for 4 weeks to allow wall development around the necrosis 2
• Consider minimally invasive approaches for debridement before open surgical necrosectomy 1
• Delay drainage as much as possible, as it is associated with fewer procedures 6
• Lumen-apposing metal stents for transgastric drainage and repeated necrosectomy are expanding interventional options 6

Specialist Care and Multidisciplinary Management

Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 1

Referral criteria:

• Patients with extensive necrotizing pancreatitis (>30% necrosis) or other complications require management in or referral to a specialist unit 1
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1
• Each case should be managed individually by a multidisciplinary specialist pancreatic team 1

Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective. 1 Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit. 1 Immunomodulation using systemic cytokine removal or anti-inflammatory drugs has shown disappointing results in clinical trials. 6