What is the treatment for pancreatitis?

Treatment of Pancreatitis

Treatment of acute pancreatitis is severity-dependent: mild cases require only supportive care with early oral feeding and goal-directed fluid resuscitation with Lactated Ringer's solution, while severe cases demand intensive care management with enteral nutrition, moderate fluid resuscitation, and intervention for complications. 1

Initial Assessment and Severity Classification

Pancreatitis must be classified as mild (80% of cases) or severe (20% of cases) immediately, as this determines the entire treatment approach 1, 2. Severe disease carries 95% of mortality and requires aggressive intervention, while mild disease has <5% mortality and needs only supportive measures 2, 3.

Management of Mild Acute Pancreatitis

Location and Monitoring

• Manage on a general medical ward with basic vital sign monitoring 1, 2
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 1, 3
• Establish peripheral venous access for fluid administration 2

Fluid Resuscitation

• Use Lactated Ringer's solution for goal-directed moderate fluid resuscitation rather than aggressive resuscitation 1
• Target urine output >0.5 ml/kg body weight 1
• Lactated Ringer's solution reduces SIRS at 24 hours, severity, mortality, and systemic/local complications compared to normal saline 4, 5

Nutritional Management

• Initiate oral feeding immediately—do not keep patients NPO 1
• Advance regular diet as tolerated with appropriate pain management 1, 2
• The outdated concept of "gut rest" has been abandoned 6

Pain Control

• Use Dilaudid as preferred opioid over morphine or fentanyl in non-intubated patients 1
• Consider epidural analgesia as adjunct in multimodal approach for severe pain 1

Antibiotics

• Do NOT use prophylactic antibiotics in mild pancreatitis—there is no evidence of benefit 1, 2, 3

Imaging

• Routine CT scanning is unnecessary unless clinical deterioration occurs 1, 2, 3

Management of Severe Acute Pancreatitis

Location and Monitoring

• All severe cases must be managed in high dependency unit or intensive care unit with full monitoring and systems support 1, 2, 3
• Establish central venous line for fluid administration and CVP monitoring 2
• Place urinary catheter for strict output monitoring 2
• Insert nasogastric tube 2
• Perform regular arterial blood gas analysis 2

Fluid Resuscitation

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1
• Aggressive fluid resuscitation in severe disease may be futile and deleterious 7, 8

Nutritional Support

• Nutritional support is essential in severe pancreatitis 6
• Attempt enteral nutrition first via nasogastric or nasoenteral tube if oral feeding not tolerated 1, 2
• Nasogastric route is effective in 80% of cases 3
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 6

Antibiotic Therapy

• Prophylactic antibiotics may be used in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1
• If used, limit duration to maximum 14 days 3
• Intravenous cefuroxime provides reasonable balance between efficacy and cost 1

Imaging

• Obtain dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days to identify pancreatic necrosis 1, 2
• Repeat CT only if clinical status deteriorates or fails to improve 2

Management of Gallstone Pancreatitis

• Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct 1, 3
• All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found 1
• Perform ERCP under antibiotic cover 2
• All patients with biliary pancreatitis should undergo definitive gallstone management during same hospital admission or within two weeks 3

Management of Pancreatic Necrosis

• Perform image-guided fine needle aspiration 7-14 days after onset for patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis 1, 3
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 3
• Infected necrosis carries 40% mortality 1
• Delay drainage as long as possible—it is associated with fewer procedures 8

Refeeding Protocol for Mild-Moderate Cases

When transitioning from fasting (2-5 days) to oral intake 6:

1. Step 1 (2-5 days): Fasting with treatment of underlying cause, analgesics, and IV fluid/electrolyte replacement 6
2. Step 2 (3-7 days): Refeeding with diet rich in carbohydrates, moderate in protein, moderate in fat—only when pain is controlled 6
3. Step 3: Advance to normal diet 6

Twenty-one percent of patients experience pain relapse during refeeding, with half occurring on days 1-2; patients with serum lipase three times upper limit and higher CT-Balthazar scores have higher relapse risk 6

Critical Pitfalls to Avoid

• Never use routine antibiotics in mild pancreatitis 1, 2, 3
• Never delay ERCP in severe gallstone pancreatitis with cholangitis 1, 3
• Never use aggressive fluid resuscitation instead of goal-directed moderate resuscitation 1, 3
• Never keep patients NPO when they can tolerate oral feeding 1
• Never overuse CT scanning in mild cases showing clinical improvement 1, 3
• Never fail to provide adequate nutritional support in severe cases 1, 3