What are the management options for pancreatitis?

Management of Acute Pancreatitis

Severity Assessment and Triage

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. 1

• 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) 2
• Mild acute pancreatitis (80% of cases) has <5% mortality and runs a self-limiting course 2
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2
• Infected necrosis with organ failure carries 35.2% mortality, while sterile necrosis with organ failure has 19.8% mortality 2

Fluid Resuscitation

Use Lactated Ringer's solution rather than normal saline for fluid resuscitation, and avoid aggressive fluid protocols in favor of moderate, goal-directed resuscitation. 3

• Lactated Ringer's solution significantly reduces systemic inflammatory response syndrome (SIRS) at 24 hours compared to normal saline (84% reduction vs 0%, P=0.035) and lowers C-reactive protein levels (51.5 vs 104 mg/dL, P=0.02) 4
• Moderate fluid resuscitation (10 ml/kg bolus if hypovolemic or no bolus if normovolemic, followed by 1.5 ml/kg/hour) is superior to aggressive resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) 3
• Aggressive fluid resuscitation increases fluid overload risk (20.5% vs 6.3%, P=0.004) without improving clinical outcomes 3
• Target urine output >0.5 ml/kg body weight 1, 2
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2

Monitoring Requirements

For severe cases, establish peripheral venous access plus central venous line for fluid administration and CVP monitoring, along with urinary catheter and nasogastric tube. 1

• Regular hourly assessment of vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 5, 1
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 5
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess adequate tissue perfusion 1
• Strict asepsis must be observed in placement and care of invasive monitoring equipment as these may serve as sources of subsequent sepsis 5

Pain Management

Use Dilaudid as first-line opioid in non-intubated patients, and integrate patient-controlled analgesia (PCA) with every pain management strategy. 1

• Pain control is a clinical priority requiring aggressive management 1, 2
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 1, 2
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1
• Avoid NSAIDs in acute kidney injury 1

Nutritional Support

Initiate early enteral nutrition rather than total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2

• Both gastric and jejunal feeding can be delivered safely 1
• Early enteral nutrition should be initiated even in severe cases 1
• Early oral feeding within 24 hours is recommended in mild cases as tolerated 2
• TPN should be avoided, but partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis, as there is no evidence they improve outcomes or reduce septic complications. 1, 2

• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths, though evidence is conflicting 1, 2
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases if used 5, 1
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1
• ERCP should always be performed under antibiotic cover 5

Management of Gallstone 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

• Severe gallstone pancreatitis with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) requires immediate therapeutic ERCP 5
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 5
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1
• For mild gallstone pancreatitis, perform laparoscopic (or open) cholecystectomy within two to four weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 5

Imaging Strategy

Obtain dynamic CT scanning with non-ionic contrast within three to 10 days of admission in severe cases to identify pancreatic necrosis and guide management. 5, 1

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 2
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1

Management of Infected Necrosis

Consider minimally invasive approaches for debridement of infected necrosis before open surgical necrosectomy. 1, 2

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 1
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 2
• Surgical debridement may be necessary for infected necrosis 1
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1
• Delaying drainage of infected collections leads to sepsis and increased mortality 2

Specialist Care and Multidisciplinary Approach

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

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 1
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 1, 2
• Each case should be managed in an individualized way 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
• Avoiding total parenteral nutrition, prophylactic antibiotics in mild cases, and overly aggressive fluid resuscitation should now be standard of care 6