What is the medical management of acute pancreatitis?

Medical Management of Acute Pancreatitis

Initial Resuscitation and Monitoring

Aggressive early fluid resuscitation within the first 12-24 hours is the single most critical intervention to prevent organ failure and reduce mortality in acute pancreatitis. 1

• Administer supplemental oxygen immediately to maintain arterial saturation greater than 95%, with continuous monitoring of oxygen saturation 1
• Target urine output greater than 0.5 ml/kg body weight per hour, monitoring central venous pressure frequently to guide fluid administration rates 1
• Crystalloid fluids are the preferred choice for resuscitation, though the optimal type and rate remain areas of active investigation 2, 3
• Early aggressive intravenous hydration is most beneficial within the first 12-24 hours and may have little benefit beyond this window 4

All patients with severe acute pancreatitis (persistent organ failure or SIRS) must be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 5, 1

Severity Assessment

• Diagnose acute pancreatitis when two of three criteria are present: characteristic upper abdominal pain, serum amylase or lipase elevation (≥3 times upper limit of normal), and characteristic imaging findings 1
• Complete severity stratification within 48 hours of diagnosis using validated scoring systems such as BISAP or APACHE II 5, 1
• Perform dynamic contrast-enhanced CT with IV contrast between 3-10 days after admission in severe cases to assess pancreatic necrosis and guide management 1, 6
• Follow-up CT should only be performed if clinical status deteriorates or fails to improve 1

Pain Management

Use a multimodal approach for pain control, with epidural analgesia as a preferred option in severe cases due to potential anti-inflammatory effects and improved splanchnic perfusion. 1, 7

• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1
• Thoracic epidural analgesia may provide prognostic benefits beyond pain control through anti-inflammatory effects and increased perfusion of splanchnic vessels 7

Nutritional Support

Initiate early enteral nutrition immediately, even in severe cases, as it is superior to parenteral nutrition in preventing gut failure and infectious complications. 1, 4

• In mild acute pancreatitis, start oral feedings immediately if there is no nausea or vomiting 4
• Both gastric and jejunal feeding routes are safe and effective 1
• Avoid parenteral nutrition as it increases infectious complications compared to enteral feeding 4

Antibiotic Therapy

Do not use prophylactic antibiotics routinely in acute pancreatitis, including cases with sterile necrosis. 1, 4

• Antibiotics may be considered in severe pancreatitis with documented infected pancreatic necrosis 1
• If antibiotics are used, intravenous cefuroxime provides a reasonable balance between efficacy and cost 1
• Maximum duration of antibiotic therapy should be 14 days in the absence of positive cultures 5
• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention and decrease morbidity and mortality 4

Management of Gallstone Pancreatitis

Perform urgent ERCP within 24-72 hours for severe gallstone pancreatitis complicated by cholangitis, jaundice, or dilated common bile duct. 1, 6

• Patients with acute pancreatitis and concurrent acute cholangitis require ERCP within 24 hours of admission 4
• Perform cholecystectomy during the same hospital admission for all patients with biliary pancreatitis, or establish a clear plan for definitive treatment within 2 weeks 5, 1
• Use pancreatic duct stents and/or postprocedure rectal NSAID suppositories to lower the risk of severe post-ERCP pancreatitis in high-risk patients 4

Management of Infected Necrosis

Use a step-up approach for infected necrosis, starting with percutaneous or endoscopic drainage, reserving minimally invasive surgical strategies only if drainage fails. 1, 7

• Delay surgical, radiologic, or endoscopic drainage for 4 weeks when possible to allow wall formation around necrosis, which reduces mortality 1, 4
• Asymptomatic pancreatic and/or extrapancreatic necrosis and pseudocysts do not warrant intervention regardless of size, location, or extension 4
• Endoscopic step-up approaches are usually superior to surgical therapy options for infected walled-off necrosis 7
• All patients with persistent symptoms and greater than 30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 5

Organizational Requirements

Every hospital receiving acute admissions must have a single nominated clinical team to manage all acute pancreatitis patients. 5, 1

• Facilities for 24-hour ERCP with sphincterotomy and stone extraction/stenting must be available 1
• Radiological facilities should permit ultrasound examination of the gallbladder within 24 hours of diagnosis 5
• Refer patients with extensive necrotizing pancreatitis or complications requiring ITU care, interventional radiology, endoscopy, or surgery to a specialist unit with a multidisciplinary pancreatic team 5, 1

Expected Outcomes

• Overall mortality should be lower than 10%, with severe acute pancreatitis mortality less than 30% 5, 1
• One-third of deaths occur in the first week from multiple organ failure, while two-thirds occur after the first week from infected necrosis 1
• Persistent organ failure beyond 48 hours is the strongest predictor of poor prognosis 7