What are the management strategies for pancreatitis?

Management of Acute Pancreatitis

Initial Triage and Severity Assessment

All patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high-dependency unit (HDU) with full monitoring and organ support. 1, 2

• Complete severity stratification within 48 hours using clinical impression, APACHE II score (≥8), C-reactive protein (>150 mg/L), Glasgow score (≥3), or persistent organ failure lasting >48 hours 3, 2
• Mild pancreatitis (80% of cases) has <5% mortality and follows a self-limiting course 2
• Severe pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2
• Infected necrosis with organ failure carries 35.2% mortality, while sterile necrosis with organ failure has 19.8% mortality 2

Fluid Resuscitation Strategy

Use lactated Ringer's solution with goal-directed moderate fluid resuscitation rather than aggressive hydration or normal saline. 4, 5

• Lactated Ringer's solution reduces severity by 31%, mortality by 62%, and decreases systemic and local complications compared to normal saline 4
• Moderate resuscitation protocol: Give 10 ml/kg bolus only if hypovolemic (no bolus if normovolemic), followed by 1.5 ml/kg/hour 5
• Avoid aggressive resuscitation: The 20 ml/kg bolus followed by 3 ml/kg/hour increases fluid overload risk 2.85-fold without improving outcomes 5
• Target urine output >0.5 ml/kg body weight 1, 2
• Avoid hydroxyethyl starch (HES) fluids as they increase multiple organ failure risk 2
• Reassess at 12,24,48, and 72 hours and adjust fluids based on clinical status 5

Monitoring Requirements

• Mild cases: Monitor temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and urine output hourly 1
• Severe cases: Place peripheral IV access, central venous line for CVP monitoring, urinary catheter, and nasogastric tube 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate regularly to assess tissue perfusion 1, 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical examination alone 2

Pain Management

Prioritize aggressive pain control with dilaudid as first-line agent in non-intubated patients. 1, 2

• Dilaudid is preferred over morphine or fentanyl 1, 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1, 2
• Consider epidural analgesia as alternative or adjunct in a multimodal approach for moderate to severe pain 1, 2
• Avoid NSAIDs in patients with acute kidney injury 1, 2

Nutritional Support

Initiate early enteral nutrition within 24 hours in mild cases and even in severe cases; avoid total parenteral nutrition. 1, 2

• Both gastric (nasogastric) and jejunal feeding routes are safe and effective 1, 2
• Nasogastric feeding is effective in 80% of cases 3
• Enteral nutrition prevents gut failure and infectious complications compared to TPN 1, 2
• Only use partial parenteral nutrition if enteral route is not completely tolerated 1, 2
• If ileus persists >5 days, parenteral nutrition will be required 1

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis or even in severe necrotizing pancreatitis. 2, 6

• No evidence supports prophylactic antibiotics improving outcomes or reducing septic complications in mild cases 2, 6
• In severe necrotizing pancreatitis, prophylactic antibiotics are not routinely recommended despite conflicting evidence 3, 2
• If prophylactic antibiotics are used in severe cases, intravenous cefuroxime for maximum 14 days is a reasonable option 3, 1
• Antibiotics are warranted only when specific infections occur: chest, urine, bile, or cannula-related 1, 2
• Always perform ERCP under antibiotic cover 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. 3, 2

• Urgent ERCP (within 24-72 hours) is indicated for: 3
  • Acute cholangitis (grade 1B evidence)
  • Common bile duct obstruction (grade 2B evidence)
  • Severe pancreatitis with increasingly deranged liver function tests
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 3, 2
• Routine ERCP is NOT indicated in acute gallstone pancreatitis without cholangitis or obstruction (grade 1A evidence) 3
• Perform laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission, to prevent recurrent pancreatitis in mild gallstone cases 2

Imaging Strategy

Obtain dynamic contrast-enhanced CT scan within 3-10 days only in severe cases to identify pancreatic necrosis. 2, 6

• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 1, 2
• Patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission require CT 3
• Follow-up CT is recommended only if clinical status deteriorates or fails to show continued improvement 1, 2
• Patients with mild pancreatitis require CT only if there is a change in clinical status suggesting new complications 1

Management of Infected Necrosis and Local Complications

Patients with >30% pancreatic necrosis and clinical suspicion of sepsis require image-guided fine needle aspiration to diagnose infection. 3

• Infected necrosis is the most serious local complication with 40% mortality 1
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 3, 2
• Consider minimally invasive approaches (endoscopic or percutaneous) before open surgical necrosectomy 2, 6
• Delaying drainage of infected collections leads to sepsis and increased mortality 6
• Local complications (pseudocyst, pancreatic abscess) often require surgical, endoscopic, or radiological intervention 1

Respiratory Support

• Institute mechanical ventilation if high-flow nasal oxygen or CPAP becomes ineffective in correcting tachypnea and dyspnea 3
• Use invasive ventilation when bronchial secretion clearance becomes ineffective or patient is tiring 3
• Apply lung-protective ventilation strategies when invasive ventilation is needed 3

Specialist Care Requirements

Every hospital receiving acute admissions should have a single nominated clinical team to manage all acute pancreatitis patients. 3, 6

• Refer patients with extensive necrotizing pancreatitis (>30% necrosis) or complications requiring ICU care, interventional radiology, endoscopy, or surgery to a specialist unit 3, 6
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2, 6

Pharmacological Treatment

• No specific pharmacological treatment beyond organ support and nutrition has proven effective 1, 2
• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1, 2

Common Pitfalls to Avoid

• Avoid aggressive fluid resuscitation: The traditional 20 ml/kg bolus followed by 3 ml/kg/hour increases fluid overload without benefit 5
• Avoid normal saline: Use lactated Ringer's solution instead, which reduces severity and mortality 4
• Avoid routine prophylactic antibiotics: They provide no benefit in mild or severe cases 2, 6
• Avoid delaying ERCP in cholangitis: This is a true emergency requiring intervention within 24-72 hours 3, 2
• Avoid routine ERCP in gallstone pancreatitis without cholangitis or obstruction: This provides no benefit and increases complications 3