What is the management approach for pancreatitis in the inpatient setting?

Management of Acute Pancreatitis in the Inpatient Setting

Presentation and Initial Assessment

All patients with severe acute pancreatitis must be managed in an ICU or HDU setting with full invasive monitoring and systems support. 1

Clinical Severity Stratification

Complete severity assessment within 48 hours using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure lasting >48 hours 2:

• Mild pancreatitis (80% of cases): <5% mortality, self-limiting course 2
• Severe pancreatitis (20% of cases): 15% hospital mortality, accounts for 95% of deaths 2
• Infected necrosis with organ failure: 35.2% mortality 2
• Sterile necrosis with organ failure: 19.8% mortality 2
• Infected necrosis without organ failure: 1.4% mortality 2

Monitoring Requirements

For mild cases 2:

• Hourly vital signs: temperature, pulse, blood pressure, respiratory rate, oxygen saturation, urine output

For severe cases, establish immediately 1:

• Peripheral venous access
• Central venous line for fluid administration and CVP monitoring
• Urinary catheter
• Nasogastric tube
• Regular arterial blood gas analysis to detect hypoxia and acidosis early 3

Fluid Resuscitation

Use moderate fluid resuscitation with lactated Ringer's solution—aggressive resuscitation increases fluid overload without improving outcomes. 4

Fluid Type Selection

Lactated Ringer's solution is superior to normal saline 5:

• Reduces SIRS at 24 hours (26.1% vs 4.2% reduction, P=0.02) 5
• Decreases organ failure and ICU stays 1
• Normal saline offers no advantage and may worsen outcomes 6

Avoid hydroxyethyl starch (HES) fluids—they increase risk of multiple organ failure 2

Resuscitation Protocol

Moderate resuscitation approach 4:

• Initial bolus: 10 ml/kg in hypovolemic patients, no bolus in normovolemic patients
• Maintenance rate: 1.5 ml/kg/hour
• Reassess at: 12,24,48, and 72 hours, adjusting based on clinical status

Avoid aggressive resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) as it causes fluid overload in 20.5% of patients versus 6.3% with moderate resuscitation (P=0.004) without improving pancreatitis severity 4

Resuscitation Targets

• Urine output: >0.5 ml/kg body weight 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1

Critical pitfall: Aggressive fluid resuscitation in predicted severe disease is futile and deleterious, particularly increasing risk of respiratory failure and acute kidney injury 7

Pain Management

Pain control is a clinical priority requiring aggressive management. 1

Analgesic Selection

• Preferred agent: Dilaudid over morphine or fentanyl in non-intubated patients 1
• Avoid NSAIDs in patients with acute kidney injury 1
• Consider epidural analgesia as alternative or adjunct in multimodal approach for moderate to severe pain 1, 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1

No evidence supports restrictions in pain medication 1

Nutritional Support

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

Feeding Protocol

For mild pancreatitis 2:

• Initiate early oral feeding within 24 hours as tolerated

For severe pancreatitis 1:

• Both gastric and jejunal feeding routes are safe
• Start early enteral nutrition even in severe cases
• If enteral route not completely tolerated, consider partial parenteral nutrition integration
• If ileus persists >5 days, parenteral nutrition is required

Avoid total parenteral nutrition as primary strategy 1

Antibiotic Therapy

Do NOT administer prophylactic antibiotics routinely in mild acute pancreatitis—there is no evidence they improve outcomes or reduce septic complications. 2

Antibiotic Indications

Prophylactic antibiotics are NOT routinely recommended even in severe acute pancreatitis with necrotizing pancreatitis, despite conflicting evidence 2

Use antibiotics only when specific infections occur 1:

• Chest infection
• Urinary tract infection
• Biliary infection
• Cannula-related infection

If prophylaxis is used in severe cases with necrosis (based on older evidence), intravenous cefuroxime provides reasonable balance between efficacy and cost 3, 1

Management of Biliary Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 1, 2

ERCP Indications and Timing

Immediate ERCP required for 3:

• Severe gallstone pancreatitis with increasingly deranged liver function tests
• Signs of cholangitis (fever, rigors, positive blood cultures)

Urgent ERCP within 48-72 hours for 3, 1:

• Failure to improve within 48 hours despite intensive resuscitation
• Severe pancreatitis with suspected gallstone etiology

All patients undergoing early ERCP require 1:

• Endoscopic sphincterotomy whether or not stones are found
• Antibiotic cover during procedure 3

Definitive Management

Patients with mild gallstone pancreatitis should undergo laparoscopic or open cholecystectomy within 2-4 weeks 3

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 1, 2

CT Indications

For severe cases 1:

• Obtain dynamic CT scanning within 3-10 days of admission using non-ionic contrast 3
• Purpose: identify pancreatic necrosis and guide management

Follow-up CT recommended only if 1:

• Patient's clinical status deteriorates
• Fails to show continued improvement in severe cases
• Change in clinical status suggesting new complication in mild cases

Management of Complications

Infected Necrosis

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

Management approach 1, 2:

• Requires intervention to completely debride all cavities containing necrotic material
• Consider minimally invasive approaches before open surgical necrosectomy
• Surgical debridement may be necessary

Critical pitfall: Delaying drainage of infected collections leads to sepsis and increased mortality 2

Other Local Complications

Pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1

Specialist Care Requirements

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

Referral Indications

Management in or referral to specialist unit necessary for 1:

• Extensive necrotizing pancreatitis (>30% necrosis)
• Other complications requiring specialized intervention

Multidisciplinary team essential involving intensivists, surgeons, gastroenterologists, and radiologists 2

Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective. 1

Despite extensive research, the following have NOT shown benefit 1:

• Antiproteases (gabexate)
• Antisecretory agents (octreotide)
• Anti-inflammatory agents

Etiological Investigation

Determine etiology in 75-80% of cases—no more than 20-25% should be classified as "idiopathic." 2

• Perform early ultrasound for gallstones
• Repeat ultrasound if initially negative 2