What is the medical management for acute pancreatitis?

Medical Management of Acute Pancreatitis

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, while mild cases can be managed on general wards with basic supportive care. 1, 2

Initial Assessment and Severity Stratification

• Complete severity stratification within 48 hours of presentation using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure lasting >48 hours 2, 3
• Mild acute pancreatitis (80% of cases) has <5% mortality and follows a self-limiting course 2, 3
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2, 3
• Infected necrosis with organ failure carries 35.2% mortality, sterile necrosis with organ failure has 19.8% mortality, and infected necrosis without organ failure only 1.4% mortality 2

Fluid Resuscitation Strategy

Use moderate fluid resuscitation with lactated Ringer's solution rather than aggressive protocols, as recent evidence shows aggressive resuscitation increases complications without improving outcomes. 4, 5

• Administer lactated Ringer's solution (preferred over normal saline) to reduce SIRS, organ failure, and ICU stays 4
• Target urine output >0.5 mL/kg body weight 1, 2
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2, 3
• Aggressive fluid resuscitation increases risk of fluid overload, respiratory failure, and acute kidney injury, particularly in severe cases 4
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess adequate tissue perfusion 1, 2

Common pitfall: Aggressive fluid resuscitation in predicted severe disease may be futile and deleterious, while moderate resuscitation achieves comparable outcomes with fewer complications. 6, 4

Monitoring Requirements

For Mild Cases:

• Hourly vital signs: temperature, pulse, blood pressure, respiratory rate, oxygen saturation, urine output 1, 2, 3

For Severe Cases:

• Peripheral venous access plus central venous line for fluid administration and CVP monitoring 7, 1
• Urinary catheter and nasogastric tube 7, 1
• Regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 7, 2
• Strict asepsis in placement and care of invasive monitoring equipment to prevent subsequent sepsis 7, 2

Pain Management

Use Dilaudid as first-line opioid in non-intubated patients, with epidural analgesia as an alternative or adjunct for moderate to severe pain. 1, 2

• Pain control is a clinical priority requiring aggressive management 1, 2, 3
• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1, 2
• Consider epidural analgesia as alternative or adjunct in a multimodal approach 1, 2, 3
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1, 2
• Avoid NSAIDs in acute kidney injury 1, 2

Nutritional Support

Initiate early enteral nutrition (within 24 hours in mild cases) via nasogastric or nasojejunal route rather than total parenteral nutrition to prevent gut failure and infectious complications. 1, 2

• Both gastric and jejunal feeding can be delivered safely 1, 2
• Early enteral nutrition should be initiated even in severe cases 1, 2
• Early oral feeding within 24 hours is recommended in mild cases as tolerated 2, 3
• Avoid TPN, but partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 1, 2
• If ileus persists for more than five days, parenteral nutrition will be required 1, 2

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis, as there is no evidence they improve outcomes or reduce septic complications. 2, 3

• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths, though evidence is conflicting 7, 1, 2
• If antibiotic prophylaxis is used in severe cases, intravenous cefuroxime is a reasonable balance between efficacy and cost 7, 2
• Maximum duration of prophylactic antibiotics should be 14 days 7
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1, 2

Common pitfall: Using prophylactic antibiotics routinely in mild cases provides no benefit and contributes to antimicrobial resistance. 2, 3

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 7, 2, 3

• Severe gallstone pancreatitis with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) requires immediate therapeutic ERCP 7, 2
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 7, 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 7, 2
• ERCP should always be performed under antibiotic cover 7, 2
• For mild gallstone pancreatitis, perform laparoscopic (or open) cholecystectomy within two to four weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 2

Imaging Strategy

Obtain dynamic CT scanning with non-ionic contrast within 3-10 days of admission in severe cases to identify pancreatic necrosis and guide management. 7, 2, 3

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 2, 3
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1, 2
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1, 2
• Patients with persistent organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require computed tomography 7

Management of Infected Necrosis

Consider minimally invasive approaches for debridement of infected necrosis before open surgical necrosectomy, as delaying drainage leads to sepsis and increased mortality. 2, 3

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 1, 2
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 7, 2
• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 7
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1, 2

Specialist Care and Multidisciplinary Approach

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 7, 1, 3

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 7, 1, 2
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2, 3

Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective in acute pancreatitis. 1, 2

• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1, 2
• Octreotide can cause cholelithiasis, biliary complications, and pancreatitis itself, and should not be used 8

Audit Standards

• Mortality should be lower than 10% overall, and less than 30% in severe (complicated) pancreatitis 7
• The correct diagnosis should be made in all patients within 48 hours of admission 7
• The etiology should be determined in at least 80% of cases with no more than 20% classified as idiopathic 7, 3
• Severity stratification should be made in all patients within 48 hours of diagnosis 7