What is the management of acute pancreatitis?

Management of Acute Pancreatitis

Severity Stratification and Initial Triage

All patients with severe acute pancreatitis must be managed in an ICU or HDU, while mild cases can be managed on general wards with basic monitoring. 1, 2

• Severity stratification should be completed within 48 hours using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure (>48 hours). 1
• Mild acute pancreatitis (80% of cases) has <5% mortality and runs a self-limiting course. 3
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality. 3
• Infected necrosis with organ failure carries 35.2% mortality, sterile necrosis with organ failure 19.8% mortality, and infected necrosis without organ failure only 1.4% mortality. 4

Fluid Resuscitation

Lactated Ringer's solution is the preferred fluid type over normal saline for resuscitation in acute pancreatitis. 5

• Lactated Ringer's solution reduces systemic inflammatory response syndrome (SIRS) by 84% at 24 hours compared to 0% reduction with normal saline (P=0.035). 5
• Lactated Ringer's also reduces C-reactive protein levels significantly compared to normal saline (51.5 vs 104 mg/dL, P=0.02). 5, 6
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure. 4
• Target urine output >0.5 ml/kg body weight. 1, 2
• Caution: Recent evidence suggests aggressive fluid resuscitation in predicted severe disease may be futile and deleterious, while early aggressive fluids benefit predicted mild severity cases most. 7

Monitoring Requirements

Mild Cases (General Ward)

• Basic vital signs: temperature, pulse, blood pressure, respiratory rate, oxygen saturation, urine output. 3, 1
• Peripheral IV access for fluids, possibly nasogastric tube; urinary catheter generally not needed. 3

Severe Cases (ICU/HDU)

• Peripheral venous access plus central venous line for fluid administration and CVP monitoring. 3, 2
• Urinary catheter and nasogastric tube mandatory. 3, 2
• Hourly vital signs including CVP, with strict asepsis for all invasive lines to prevent subsequent sepsis. 3
• Regular arterial blood gas analysis essential as hypoxia and acidosis may be detected late clinically. 3
• Swan-Ganz catheter required if cardiocirculatory compromise exists or initial resuscitation fails. 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion. 2, 4

Pain Management

Dilaudid is preferred over morphine or fentanyl in non-intubated patients. 1, 2, 4

• Pain control is a clinical priority requiring aggressive management. 1, 2, 4
• Consider epidural analgesia as alternative or adjunct in a multimodal approach for moderate to severe pain. 1, 2, 4
• Integrate patient-controlled analgesia (PCA) with every pain management strategy. 2, 4
• Avoid NSAIDs in patients with acute kidney injury. 2, 4

Nutritional Support

Enteral nutrition is strongly preferred over total parenteral nutrition to prevent gut failure and infectious complications. 1, 2, 4

• Early oral feeding within 24 hours is recommended in mild cases as tolerated. 4
• Both nasogastric and nasojejunal routes are acceptable and equally safe for enteral nutrition. 1, 2, 4
• Early enteral feeding should be initiated even in severe cases. 1, 2
• If ileus persists beyond 5 days, parenteral nutrition will be required. 1, 2, 4
• Partial parenteral nutrition can be integrated if enteral route is not completely tolerated. 2

Antibiotic Therapy

Antibiotics should NOT be administered routinely in mild acute pancreatitis as there is no evidence they improve outcomes or reduce septic complications. 3, 1, 2

• In severe acute pancreatitis with necrotizing pancreatitis, prophylactic antibiotics are not routinely recommended despite conflicting evidence. 1, 4
• If prophylactic antibiotics are used in severe cases, limit to maximum 14 days. 1
• Intravenous cefuroxime is a reasonable balance between efficacy and cost when prophylaxis is indicated. 2, 4
• Antibiotics ARE warranted when specific infections occur: respiratory, urinary tract, biliary, or catheter-related. 3, 1, 2, 4
• All patients with persistent symptoms and >30% pancreatic necrosis or clinical sepsis should undergo image-guided fine needle aspiration for culture 7-14 days after onset. 2, 4

Management of Biliary Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 1, 2, 4

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found. 1, 2
• Cholecystectomy should be performed during the same hospital admission unless a clear plan exists for definitive treatment within 2 weeks. 1
• For unfit patients, endoscopic sphincterotomy alone is adequate treatment. 4
• Delay cholecystectomy in severe acute pancreatitis until lung injury and systemic disturbance resolve. 4

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 3, 1

• Dynamic CT scanning should be obtained in severe cases to identify pancreatic necrosis and guide management. 2, 4
• Patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission require CT scanning. 1
• Follow-up CT is recommended only if clinical status deteriorates or fails to show continued improvement. 2, 4
• Early ultrasound should be performed for gallstones and repeated if initially negative. 3

Management of Infected Necrosis

Infected necrosis requires intervention to completely debride all cavities containing necrotic material. 1, 2

• Infected necrosis is the most serious local complication with 40% mortality. 2, 4
• Consider minimally invasive approaches before open surgical necrosectomy. 2, 4
• Options include percutaneous drainage and surgical debridement with thorough removal of necrotic tissue. 4
• The choice of surgical technique depends on individual features and locally available expertise. 1

Specific Pharmacological Treatments to AVOID

No specific pharmacological treatments beyond organ support and nutrition have proven effective. 2, 4

• Aprotinin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have no proven value and cannot be recommended. 3
• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit. 2

Specialist Care and Multidisciplinary Approach

Every hospital receiving acute admissions should have a single nominated clinical team to manage all acute pancreatitis patients. 1, 2, 4

• Management in or referral to a specialist unit is necessary for extensive necrotizing pancreatitis (>30% necrosis) or other complications. 1, 2, 4
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential. 4

Etiological Investigation

• The etiology should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic". 3, 1
• Early ultrasound for gallstones should be repeated if initially negative. 3
• ERCP is indicated with jaundice, dilated common duct, or recurrent attacks to exclude anatomical variations, tumors, and common duct stones. 3
• CT scan should be performed when etiology remains obscure (particularly in elderly) to exclude pancreatic tumor. 3

Common Pitfalls to Avoid

• Delaying drainage of infected collections leads to sepsis and increased mortality. 1
• Using prophylactic antibiotics routinely in mild cases provides no benefit. 3, 1, 2
• Delaying enteral nutrition unnecessarily increases infectious complications. 1
• Aggressive fluid resuscitation in predicted severe disease may be harmful rather than beneficial. 7