What is the management and treatment of pancreatitis?

Management and Treatment of Acute Pancreatitis

Initial Diagnosis and Severity Classification

Acute pancreatitis requires two of three criteria: characteristic abdominal pain, serum lipase/amylase ≥3× upper limit of normal, and/or imaging findings of pancreatic inflammation 1, 2. Lipase is preferred over amylase when available for superior diagnostic accuracy 1.

The disease must be classified as mild (80% of cases) or severe (20% of cases) within 48 hours, as this fundamentally determines management intensity and mortality risk 1, 3. Severe pancreatitis carries 13-35% mortality versus <1-3% for mild disease 1, 3.

Severity Assessment Tools

• Use APACHE II score, Glasgow score ≥3, C-reactive protein >150 mg/L, or persistent organ failure beyond 48 hours to identify severe disease 1, 3
• Obesity and clinical impression of severity within the first 24 hours are also valid predictors 1
• Patients with persistent organ failure (cardiovascular, respiratory, renal) have the highest mortality risk, especially when combined with infected necrosis 1

Essential Initial Workup

• Obtain serum aminotransferases, bilirubin, triglycerides, calcium, complete blood count, renal function, glucose, and liver function tests 4, 5
• Perform transabdominal ultrasound early to detect gallstones; repeat if initially negative 4
• Document alcohol intake in units per week to identify alcohol etiology 4
• Review all medications for drug-induced pancreatitis 4

---

Management of Mild Acute Pancreatitis

Mild pancreatitis can be managed on general medical wards with basic vital sign monitoring (temperature, pulse, blood pressure, urine output) 1, 3.

Core Treatment Elements

• Provide intravenous fluid resuscitation via peripheral access 1, 3
• Advance oral diet as tolerated with oral analgesics 3
• Do NOT administer prophylactic antibiotics—there is no evidence they improve outcomes or reduce septic complications in mild disease 1, 3
• Avoid routine CT scanning unless clinical deterioration occurs 1, 3

---

Management of Severe Acute Pancreatitis

All severe cases must be managed in a high-dependency unit (HDU) or intensive care unit (ICU) with comprehensive monitoring and multidisciplinary support 1, 3.

Immediate Resuscitation Requirements

• Establish peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 1, 3
• Maintain strict asepsis with all invasive lines to prevent subsequent sepsis in the setting of pancreatic necrosis 1
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature, and cumulative fluid balance 1, 3
• Perform regular arterial blood gas analysis, as hypoxia and acidosis may be clinically occult 1

Advanced Hemodynamic Monitoring

• Insert Swan-Ganz catheter when cardiocirculatory compromise exists or initial resuscitation fails to produce improvement 1, 3, 6
• Measure pulmonary artery wedge pressure, cardiac output, and systemic resistance 1

Fluid Resuscitation Strategy

• Provide aggressive early fluid resuscitation, though moderate resuscitation is preferred over excessive volumes 3
• Adjust fluid dosing continuously based on circulatory dynamics assessment 7
• Large fluid volumes are typically required in severe disease 7

Oxygenation

• Continuously monitor oxygen saturation and administer supplemental oxygen to maintain arterial saturation >95% 3

Nutritional Support

• Provide enteral nutrition (oral, nasogastric, or nasojejunal route) if nutritional support is required 1, 3
• The nasogastric route is effective in 80% of cases 1
• Enteral feeding is superior to parenteral nutrition, reducing death, multiorgan failure, local complications, and systemic infections 1, 8, 2

Antibiotic Prophylaxis Controversy

The evidence on prophylactic antibiotics remains conflicting and lacks consensus 1, 3. Some trials demonstrate benefit while others do not 1.

• If prophylactic antibiotics are used, limit duration to maximum 14 days 1
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost when antibiotics are chosen 1, 6
• Treat confirmed infections with appropriate antibiotics regardless of prophylaxis decisions 1
• In severe cases with >30% necrosis, imipenem/cilastatin may decrease pancreatic infection risk 8

Imaging Protocol

• Obtain dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days of admission 1, 3, 6
• Perform follow-up CT only if clinical deterioration occurs or improvement plateaus 3
• Patients with persistent symptoms and >30% necrosis, or those with smaller necrosis but clinical suspicion of sepsis, require image-guided fine needle aspiration 1

---

Management of Gallstone Pancreatitis

Treatment strategy depends on disease severity, presence of jaundice, and signs of cholangitis 1, 3, 6.

Urgent ERCP Indications

Perform immediate therapeutic ERCP when cholangitis is present (fever, rigors, positive blood cultures, deranged liver function tests) 1, 6. This is a medical emergency.

Perform urgent ERCP within 72 hours (ideally within 48 hours) in severe gallstone pancreatitis when the patient fails to improve despite intensive resuscitation 1, 6.

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1
• ERCP must always be performed under antibiotic cover 3, 6
• Facilities for 24-hour ERCP with sphincterotomy and stone extraction must be available 1, 6

Definitive Biliary Management

All patients with biliary pancreatitis should undergo definitive gallstone management during the same hospital admission, unless a clear plan exists for treatment within two weeks 1, 6.

• Perform laparoscopic cholecystectomy within 2 weeks, preferably during index admission 6
• Do not delay surgery beyond 4 weeks, as this significantly increases recurrent biliary events including repeat pancreatitis 6
• Defer cholecystectomy only until inflammatory process subsides and surgery is technically safer 6
• For patients unfit for surgery, ERCP with sphincterotomy alone provides adequate long-term therapy, though with slightly higher risk of biliary complications 6

---

Management of Pancreatic Necrosis

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1.

• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1
• Refer all patients with local complications to specialist tertiary centers 5
• Delay intervention when possible, as well-organized necrosis (walled-off necrosis) typically takes 4 weeks or more to mature 1

---

Critical Pitfalls to Avoid

Antibiotic Misuse

• Never routinely administer antibiotics in mild pancreatitis—no evidence supports this practice 1, 3

ERCP Timing Errors

• Do not delay ERCP in severe gallstone pancreatitis with cholangitis—this is an emergency 1, 6
• Avoid routine preoperative ERCP in mild cases without CBD dilatation, detected stones, or abnormal liver function tests 6

Cholecystectomy Delays

• Never delay cholecystectomy beyond 2-4 weeks, as recurrent biliary events increase dramatically 6

Etiologic Workup Failures

• Do not accept >20-25% idiopathic cases—this suggests inadequate workup 4
• Obtain complete alcohol history in units per week, not vague descriptions 4
• Measure triglycerides and calcium after the acute phase if etiology remains unclear 4

Nutritional Support Errors

• Do not keep patients NPO unnecessarily—early enteral feeding protects gut mucosal barrier and reduces bacterial translocation 6

Monitoring Inadequacy

• Do not rely on clinical assessment alone for hypoxia and acidosis—perform regular arterial blood gases 1

---

Specific Pharmacologic Treatments to Avoid

Do not use aprotinin, glucagon, somatostatin, fresh frozen plasma, or peritoneal lavage—none have proven value 1.