What is the treatment for acute pancreatitis?

Treatment of Acute Pancreatitis

Immediate Classification and Risk Stratification

The first critical step is to classify pancreatitis severity immediately upon presentation, as this determines the entire treatment pathway—mild disease (80% of cases) carries <5% mortality and requires only supportive care on general wards, while severe disease (20% of cases) accounts for 95% of deaths and mandates ICU-level aggressive intervention. 1, 2

Management of Mild Acute Pancreatitis

Setting and Monitoring

• Manage on general medical ward with basic vital sign monitoring (temperature, pulse, blood pressure, urine output) 3, 1
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 3, 1

Fluid Resuscitation

• Use Lactated Ringer's solution as the preferred crystalloid—it significantly reduces systemic inflammatory response syndrome (SIRS) by 84% at 24 hours compared to normal saline and lowers C-reactive protein levels (51.5 vs 104 mg/dL). 4
• Administer goal-directed moderate fluid resuscitation targeting urine output >0.5 ml/kg body weight 1
• In mild pancreatitis without SIRS, early aggressive hydration (20 ml/kg bolus followed by 3 ml/kg/h) hastens clinical improvement compared to standard rates, with 70% vs 42% showing improvement at 36 hours 5

Nutrition and Pain Management

• Initiate oral feeding immediately and advance regular diet as tolerated—there is no benefit to prolonged fasting. 1
• 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 administer prophylactic antibiotics in mild pancreatitis—there is no evidence they affect outcomes or reduce septic complications. 3, 1, 2
• Reserve antibiotics only for specific documented infections (chest, urine, bile, or line-related) 3

Imaging

• Routine CT scanning is unnecessary unless clinical deterioration occurs 3, 2, 6

Management of Severe Acute Pancreatitis

Setting and Intensive Monitoring

• All severe cases must be managed in high dependency unit (HDU) or intensive care unit (ICU) with full multidisciplinary systems support. 1, 2
• Establish peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 1, 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 3, 2
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 3, 2

Fluid Resuscitation Strategy

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution—recent evidence shows aggressive fluid resuscitation in severe disease may be futile and deleterious, increasing mortality and adverse events. 7, 8
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1
• Target urine output >0.5 ml/kg body weight 3, 1

Critical pitfall to avoid: The paradigm has shifted away from early aggressive fluid resuscitation in severe pancreatitis, as high fluid rates are associated with increased mortality compared to moderate rates 7, 8

Nutritional Support

• Attempt enteral nutrition first via nasogastric or nasoenteral tube if oral feeding not tolerated—the nasogastric route is effective in 80% of cases. 2, 6
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 1, 6

Prophylactic Antibiotics

• Use prophylactic antibiotics in severe acute pancreatitis with evidence of pancreatic necrosis >30%, limiting duration to maximum 14 days. 1, 6
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 3, 2
• Evidence remains conflicting—meta-analyses show potential reduction in mortality (odds ratio 0.32) and infected necrosis (odds ratio 0.51), but significant heterogeneity exists between trials 3, 6

Imaging Protocol

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

Management of Gallstone Pancreatitis

Timing of ERCP

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

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 6

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, 6
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 1, 6

Therapies Without Proven Benefit

There is no proven specific drug therapy for acute pancreatitis—antiproteases (gabexate), antisecretory agents (octreotide), anti-inflammatory agents (lexipafant), aprotinin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have all proven disappointing in large randomized studies. 3, 6