What is the management and treatment for a patient presenting with symptoms of pancreatitis?

Management and Treatment of Pancreatitis

All patients presenting with symptoms of acute pancreatitis should be immediately hospitalized for diagnosis confirmation, severity stratification, and aggressive initial management within the first 48-72 hours, as this early intervention directly impacts morbidity and mortality. 1, 2

Immediate Assessment and Triage

Upon presentation, rapidly assess for:

• Signs of organ failure (respiratory distress, hypotension, altered mental status, oliguria) to determine need for ICU/HDU admission 1
• Hemodynamic instability requiring immediate resuscitation 3
• Systemic inflammatory response syndrome (SIRS) criteria 3

Patients with severe acute pancreatitis must be managed in an HDU or ITU setting with full monitoring and systems support, including peripheral and central venous access, urinary catheter, nasogastric tube, and hourly vital sign monitoring (pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature). 1

Fluid Resuscitation

Aggressive intravenous hydration should be initiated immediately in all patients unless cardiovascular or renal comorbidities preclude it. 3

• Ringer's lactate is preferred over normal saline based on recent evidence 4
• Maximum benefit occurs within the first 12-24 hours of presentation 3
• Large fluid volumes are typically required in severe cases, adjusted based on continuous CVP monitoring and urine output 1, 5
• In patients with cardiocirculatory compromise or failed initial resuscitation, Swan-Ganz catheter placement is required for pulmonary artery wedge pressure and cardiac output monitoring 1

Pain Management

Use a multimodal analgesic approach prioritizing NSAIDs with or without acetaminophen as first-line therapy. 2

• Intravenous opiates are safe when used judiciously for moderate to severe pain 3, 6
• Always prescribe laxatives concurrently with opioids to prevent constipation 2
• Consider epidural analgesia for patients requiring prolonged high-dose opioids 7

Diagnostic Imaging

Reserve contrast-enhanced CT or MRI for patients with unclear diagnosis or failure to improve clinically. 3

• Dynamic CT scanning with non-ionic contrast should be obtained within 3-10 days of admission to assess for necrosis 1, 7
• Initial diagnosis relies on clinical symptoms plus elevated lipase 3, 6
• Obtain right upper quadrant ultrasound in all patients to evaluate for gallstone etiology 3, 6

Antibiotic Management

Prophylactic antibiotics are NOT routinely recommended for prevention of pancreatic necrosis infection. 7, 3

However, there is conflicting evidence:

• Older UK guidelines suggest intravenous cefuroxime may reduce septic complications in severe cases 1
• If prophylactic antibiotics are used, limit duration to maximum 14 days 7
• Antibiotics should be administered when specific infections are confirmed 7, 3
• All ERCPs must be performed under antibiotic cover 1

Nutritional Support

In mild pancreatitis, oral feeding can be started immediately if no nausea or vomiting is present. 3

In severe pancreatitis, enteral nutrition via nasogastric or nasojejunal tube is strongly recommended over parenteral nutrition to prevent gut failure and infectious complications. 7, 3, 4

• Both gastric and jejunal feeding routes are safe 7
• Reserve parenteral nutrition only for patients who cannot tolerate enteral nutrition 7, 3
• Early enteral feeding should be encouraged, not avoided 4

Management of Gallstone Pancreatitis

Urgent ERCP Indications

Urgent therapeutic ERCP should be performed within 72 hours in patients with:

• Cholangitis (fever, rigors, positive blood cultures) - requires immediate ERCP 1
• Jaundice with increasingly deranged liver function tests 1
• Dilated common bile duct 1
• Predicted or actual severe pancreatitis with suspected gallstone etiology 1

All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found. 1

Definitive Treatment Timing

Patients with mild gallstone pancreatitis should undergo cholecystectomy during the same hospital admission or within 2 weeks of discharge. 1, 2

This is critical because:

• Delay beyond 2 weeks dramatically increases risk of potentially fatal recurrent pancreatitis 1, 2
• Laparoscopic or open cholecystectomy with operative cholangiography is preferred 1
• For unfit patients, endoscopic sphincterotomy alone is adequate 1

In severe acute pancreatitis, delay cholecystectomy until signs of lung injury and systemic disturbance have resolved. 1

Management of Pancreatic Necrosis

Patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided fine needle aspiration for culture 7-14 days after onset. 1, 7

For infected necrosis:

• Delay intervention until at least 4 weeks after disease onset when possible to allow wall formation and reduce mortality 7
• Use a step-up approach: start with percutaneous or endoscopic drainage, progress to minimally invasive necrosectomy only if no improvement 7
• Patients with infected necrosis require complete debridement of all necrotic material 1

Early intervention is indicated only for:

• Abdominal compartment syndrome unresponsive to conservative management 7
• Acute ongoing bleeding when endovascular approach fails 7
• Bowel ischemia or acute necrotizing cholecystitis 7

Critical Pitfalls to Avoid

• Never discharge patients before completing severity assessment within 48 hours, as organ failure can develop after initial presentation 2
• Never delay gallstone management beyond 2 weeks - this exposes patients to potentially fatal recurrent pancreatitis 1, 2
• Never prescribe opioids without concurrent laxatives - constipation is predictable and preventable 2
• Never perform routine ERCP in mild pancreatitis without cholangitis, jaundice, or ductal dilatation 1, 3
• Avoid parenteral nutrition when enteral feeding is possible 3, 4

Disposition and Follow-up

Patients with confirmed mild pancreatitis may be considered for early discharge only after:

• No organ failure present 2
• Tolerating oral intake 2
• Pain adequately controlled 2
• No complications on imaging 2
• Etiology identified and addressed 2

Discharged patients require close outpatient follow-up within 1-2 weeks with clear return precautions for worsening pain, fever, inability to tolerate oral intake, or jaundice. 2