What are the guidelines for acute pancreatitis?

From the Guidelines

The management of acute pancreatitis should prioritize goal-directed fluid therapy, with the most recent evidence suggesting that aggressive intravenous hydration may not be beneficial for all patients, particularly those with non-severe acute pancreatitis 1. The initial treatment of acute pancreatitis includes bowel rest, pain management with opioid analgesics, and nutritional support.

• The choice of fluid for resuscitation is crucial, with lactated Ringer's solution being a common choice, although the evidence does not support a clear benefit over normal saline 1.
• The American Gastroenterological Association (AGA) recommends goal-directed therapy for fluid management, with a conditional recommendation for using either normal saline or Ringer’s lactate 1.
• Enteral feeding is preferred over parenteral nutrition when possible, and early oral feeding is recommended as tolerated, rather than keeping the patient nil per os 1.
• Cholecystectomy is recommended during the initial admission for patients with acute biliary pancreatitis, and brief alcohol intervention is recommended for patients with acute alcoholic pancreatitis 1.
• Monitoring for complications like pseudocysts, necrosis, or organ failure is essential, and antibiotics are not routinely recommended unless there's evidence of infection or necrotizing pancreatitis 1. The most recent and highest quality study on this topic is a systematic review and meta-analysis published in 2023, which compared the effects of aggressive and non-aggressive intravenous hydration in acute pancreatitis 1.
• This study found that aggressive intravenous hydration did not reduce mortality in acute pancreatitis, and may even increase the risk of fluid overload and mortality in patients with non-severe acute pancreatitis 1.
• Therefore, a more conservative approach to fluid resuscitation may be warranted, particularly in patients with non-severe acute pancreatitis, to minimize the risk of complications and improve outcomes.

From the Research

Guideline for Pancreatitis

• The initial management of acute pancreatitis (AP) is crucial and includes assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis 2.
• Recent updates suggest a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution 2, 3.
• The use of lactated Ringer's solution has been shown to reduce systemic inflammation compared to normal saline in patients with AP 3.
• Aggressive fluid resuscitation has been associated with higher mortality compared to moderate fluid replacement in patients with AP 4.
• Nonopioid analgesics should be the first line of analgesia in patients with AP, and statin use may be associated with a lower incidence of AP 5.
• The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has been investigated to distinguish between inflammation and infection in patients with AP 2.
• Early enteral feeding is becoming a definitive treatment approach, and urgent ERCP should only be performed in patients with gallstone pancreatitis and cholangitis 2, 6.
• Convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is important for improving prognosis and preventing recurrence in patients with AP 2.