What is the treatment for acute pancreatitis?

Treatment of Acute Pancreatitis

Immediate Severity Classification and Triage

The first critical step is to classify pancreatitis as mild or severe immediately upon presentation, as this determines the entire treatment pathway—severe disease carries 95% of mortality and requires ICU-level care, while mild disease has <5% mortality and needs only supportive measures on a general ward 1, 2.

Management of Mild Acute Pancreatitis (80% of cases)

Setting 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 1, 4
• Ringer's lactate is superior to normal saline in reducing SIRS, organ failure, and ICU stays 4
• Target urine output >0.5 ml/kg body weight 1
• Avoid aggressive fluid resuscitation—the 2022 WATERFALL trial demonstrated that aggressive resuscitation (20 ml/kg bolus + 3 ml/kg/hr) resulted in 20.5% fluid overload versus 6.3% with moderate resuscitation (10 ml/kg or no bolus + 1.5 ml/kg/hr), without improving clinical outcomes 5

Nutrition and Pain Management

• Initiate oral feeding immediately and advance regular diet as tolerated 1, 2
• Use Dilaudid as preferred opioid over morphine or fentanyl in non-intubated patients 1
• Consider epidural analgesia as adjunct 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 6, 2, 3

Management of Severe Acute Pancreatitis (20% of cases)

Setting and Monitoring

• All severe cases must be managed in HDU or ICU with full monitoring and systems support 6, 1, 2, 3
• Establish peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 6, 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 6
• Monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 6
• If cardiocirculatory compromise exists or initial resuscitation fails, use Swan-Ganz catheter for pulmonary artery wedge pressure, cardiac output, and systemic resistance measurement 6

Fluid Resuscitation

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution 1, 4
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1
• Elevated hematocrit, BUN, or creatinine should prompt more intensive early resuscitation 7

Nutritional Support

• 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 1
• Commence enteral feeding 48 hours after presentation 8

Antibiotics

• Use prophylactic antibiotics in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 6
• Limit duration to maximum 14 days 1, 3
• Note: Evidence on antibiotic prophylaxis remains conflicting, with some guidelines stating no consensus 3

Imaging

• Perform dynamic CT scanning with non-ionic contrast within 3-10 days of admission 6, 2
• Perform follow-up CT only if clinical status deteriorates or fails to show continued improvement 2

Management of Gallstone Pancreatitis

Urgent ERCP Indications

• Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct 1, 3, 8
• If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 6
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 6
• Always perform ERCP under antibiotic cover 6, 2, 3

Definitive Management

• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan exists for treatment 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
• Intervene to completely debride all cavities containing necrotic material in patients with infected necrosis 1, 3

Critical Pitfalls to Avoid

• Aggressive fluid overload: The WATERFALL trial definitively showed aggressive resuscitation increases fluid overload (20.5% vs 6.3%) without clinical benefit 5
• Routine antibiotics in mild disease: No evidence supports this practice 1, 2, 3
• Delaying ERCP in severe gallstone pancreatitis with cholangitis: This requires immediate intervention 6, 3
• Overuse of CT scanning: Only indicated for severe disease or clinical deterioration 6, 2, 3
• Inadequate nutritional support: Enteral nutrition should be attempted first in severe cases 1, 2, 3