From the Guidelines
The management of acute pancreatitis should focus on supportive care, pain control, and preventing complications, with an emphasis on early oral feeding, enteral nutrition, and selective use of antibiotics, as recommended by the most recent guidelines 1. The initial treatment includes aggressive intravenous fluid resuscitation with lactated Ringer's solution, adjusted based on vital signs and urine output. Pain management typically involves opioid analgesics such as morphine or hydromorphone.
- Key aspects of management include:
- Early oral feeding as soon as the patient can tolerate it, usually within 24 hours, as recommended by the American Gastroenterological Association 1
- Enteral nutrition (oral, NG, or NJ) if oral feeding is not tolerated, with parenteral nutrition as an alternative 1
- IV pain medications and early fluid resuscitation
- Mechanical ventilation for severe cases
- Selective use of antibiotics for confirmed infections, with prophylactic antibiotics no longer recommended for all patients with acute pancreatitis 1
- ERCP should be performed as soon as possible in patients with acute biliary pancreatitis and common bile duct obstruction 1
- Cholecystectomy during the initial admission is recommended for patients with acute biliary pancreatitis, as well as brief alcohol intervention for those with acute alcoholic pancreatitis 1 The underlying pathophysiology involves premature activation of pancreatic enzymes leading to autodigestion and inflammation, so treatment aims to rest the pancreas while supporting the patient through the inflammatory process.
- Monitoring for complications such as pancreatic necrosis, pseudocysts, or organ failure is crucial, with severe cases requiring ICU admission. The goal of treatment is to reduce morbidity, mortality, and improve quality of life, with a focus on individualized care and selective use of interventions, as supported by the most recent and highest quality evidence 1.
From the Research
Management of Acute Pancreatitis
The management of acute pancreatitis (AP) involves several key components, including:
- Initial therapy with adequate fluid resuscitation, nutrition, analgesia, and critical care support when necessary 2
- Avoiding total parenteral nutrition and prophylactic antibiotics, as well as overly aggressive fluid resuscitation 3
- Initiating early feeding and using minimally invasive approaches to infected necrosis 3, 4
- Assessing the prognosis and informing management through clinical evolution, laboratory, and radiological assessment 4
- Using a step-up approach, which has been shown to be effective in the majority of cases 4
Fluid Resuscitation
Fluid resuscitation is a critical component of AP management, with the goal of preventing hypovolemia and organ hypoperfusion. The choice of fluid for resuscitation is important, with:
- Lactated Ringer's (LR) potentially having advantages over normal saline (NS) due to its buffered crystalloid properties 5
- A retrospective database analysis showing an association between the use of LR as initial resuscitation fluid and reduced 1-year mortality in patients hospitalized with AP 5
Nutrition and Follow-up Care
Nutrition and follow-up care are also important aspects of AP management, with: