What is the management of acute pancreatitis?

From the Guidelines

Management of acute pancreatitis should prioritize goal-directed fluid therapy, early enteral nutrition, and supportive care to reduce morbidity, mortality, and improve quality of life. The initial treatment includes aggressive IV fluid resuscitation with lactated Ringer's solution, adjusted based on vital signs and urine output 1. Pain should be controlled with opioid analgesics such as morphine or hydromorphone. Early enteral nutrition within 24-48 hours is recommended, preferably via oral route if tolerated, or nasojejunal feeding if necessary, as it reduces the incidence of nosocomial infection, and decreases the duration of systemic inflammatory response syndrome (SIRS) and overall disease severity 1. Patients should be NPO only if experiencing intractable nausea, vomiting, or severe pain.

• Key aspects of management include:
  • Aggressive IV fluid resuscitation
  • Early enteral nutrition
  • Pain control with opioid analgesics
  • Monitoring for complications like pseudocysts, necrosis, or organ failure
  • Addressing the underlying cause, such as gallstone removal for biliary pancreatitis or alcohol cessation counseling
• The use of prophylactic antibiotics is not recommended unless there is confirmed infection or necrotizing pancreatitis 1.
• Enteral nutrition is preferred over parenteral nutrition, and the jejunal route is recommended if gastric feeding is not tolerated 1.
• Severe cases require ICU admission for closer monitoring, and mechanical ventilation may be necessary 1. The most recent and highest quality study 1 suggests that aggressive intravenous hydration may not be beneficial in all cases, and a goal-directed approach should be used instead.

From the Research

Acute Pancreatitis Management

• The management of acute pancreatitis involves intravenous fluid resuscitation as the cornerstone of early treatment 2.
• The choice of fluid type is crucial, with Lactated Ringer's solution being preferred over normal saline based on animal studies, clinical trials, and meta-analyses 2, 3, 4.

Fluid Resuscitation Approaches

• There is a wide variation in fluid resuscitation approaches in current guideline recommendations, quality indicators, and worldwide practice patterns 2.
• Early aggressive fluid therapy may have the highest benefit in patients with predicted mild severity, while aggressive resuscitation in patients with predicted severe disease might be futile and deleterious 2.
• Lactated Ringer's solution has been shown to reduce the risk of moderate-to-severe acute pancreatitis, shorten hospital stay, and reduce ICU admission rates compared to normal saline 3, 4, 5.

Comparison of Lactated Ringer's Solution and Normal Saline

• Studies have consistently shown that Lactated Ringer's solution is associated with a lower risk of developing moderate-to-severe acute pancreatitis, local complications, and ICU admission rates compared to normal saline 3, 4, 5, 6.
• Lactated Ringer's solution has also been shown to have an anti-inflammatory effect in patients with acute pancreatitis, with a direct effect of lactate on inhibiting the induction of inflammatory phenotype of macrophages and NF-κB activation 6.

Clinical Outcomes

• Hospital mortality rates have been shown to be lower in patients resuscitated with Lactated Ringer's solution compared to normal saline 5.
• ICU length of stay has been shown to be longer in patients resuscitated with Lactated Ringer's solution compared to normal saline, although this finding may not be statistically significant 5.