What is the treatment approach for pancreatitis?

Treatment Approach for Acute Pancreatitis

All patients with severe acute pancreatitis require immediate admission to an intensive care unit or high dependency unit with full monitoring and systems support, while mild cases can be managed on general wards with basic vital sign monitoring. 1, 2

Initial Assessment and Severity Stratification

Severity stratification must be completed within 48 hours of admission using clinical impression, obesity, APACHE II score, C-reactive protein >150 mg/l, Glasgow score ≥3, or persisting organ failure. 1 Patients with persistent organ failure beyond 48 hours have the highest mortality risk and require ICU-level care. 1

• Mild pancreatitis (80% of cases): mortality <1-3% 1
• Severe pancreatitis (20% of cases): mortality 13-35%, rising to 40% with infected necrosis 1, 3

Fluid Resuscitation

Use goal-directed moderate fluid resuscitation with lactated Ringer's solution rather than aggressive hydration with normal saline. 2, 4 This represents a major paradigm shift from historical aggressive protocols. 4

• Target urine output >0.5 ml/kg body weight 2, 5
• Maximum benefit occurs within the first 12-24 hours 6
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 2
• Avoid hydroxyethyl starch (HES) fluids as they increase multiple organ failure risk 3

Nutritional Management

Initiate oral feeding immediately in mild pancreatitis if there is no nausea or vomiting—do not keep patients NPO. 2, 6 This is a fundamental departure from traditional practice. 2

• If oral feeding is not tolerated, use enteral nutrition via nasogastric or nasojejunal tube 2, 5
• Nasogastric feeding is effective in 80% of cases and equally safe as jejunal feeding 1, 5
• Enteral nutrition is superior to total parenteral nutrition (TPN) for preventing infectious complications, multiorgan failure, and death 2, 6, 7
• Reserve TPN only if ileus persists beyond 5 days 5

Pain Management

Dilaudid is preferred over morphine or fentanyl in non-intubated patients. 2, 5

• Consider epidural analgesia as an alternative or adjunct in a multimodal approach 2, 5, 3
• Pain control is a clinical priority requiring immediate attention 2, 5

Antibiotic Therapy

Do not use prophylactic antibiotics routinely in mild acute pancreatitis or biliary pancreatitis. 1, 2, 5

The evidence regarding prophylactic antibiotics in severe necrotizing pancreatitis remains conflicting. 1, 5 However:

• In severe acute pancreatitis with >30% pancreatic necrosis, prophylactic antibiotics (particularly imipenem/cilastatin) may reduce complications and deaths 2, 7
• If prophylactic antibiotics are used, limit duration to maximum 14 days 1
• Antibiotics are warranted for specific documented infections (respiratory, urinary, biliary, catheter-related) 1, 5
• In infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention and decrease mortality 6

Management of Biliary Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 1

• Do not perform ERCP in the absence of cholangitis—this is critical 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1
• Patients with cholangitis require sphincterotomy or stenting within 24 hours 1, 6

Timing of Cholecystectomy

All patients with biliary pancreatitis should undergo cholecystectomy during the same hospital admission, unless a clear plan exists for definitive treatment within two weeks. 1, 2

• Delay beyond two weeks exposes patients to risk of potentially fatal recurrent pancreatitis 1
• In severe pancreatitis, delay cholecystectomy until lung injury and systemic disturbance resolve 1

Imaging

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 2, 5

• Patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission require CT scanning 1, 5
• Dynamic contrast-enhanced CT should be obtained in severe cases within 3-10 days to identify pancreatic necrosis 2, 3
• Use non-ionic contrast for CT imaging 3

Management of Pancreatic Necrosis

All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration for culture 7-14 days after onset. 1

Infected Necrosis

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 1

• Use a step-up approach: start with percutaneous or endoscopic drainage, which resolves infection in 25-60% of patients without further intervention 3
• Delay intervention preferably for 4 weeks to allow wall formation around necrosis 3, 6
• If drainage fails, consider minimally invasive strategies: transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD) 3
• Postponing surgical intervention beyond 4 weeks results in lower mortality 3

Indications for Early Surgical Intervention

Only two scenarios warrant early surgery:

• Abdominal compartment syndrome unresponsive to conservative management 3
• Acute ongoing bleeding when endovascular approach fails 3

Monitoring Requirements

Mild Pancreatitis

• Basic vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, temperature 5
• Peripheral intravenous line for fluid administration 5
• Nasogastric tube if needed 5

Severe Pancreatitis

• Hourly vital signs including central venous pressure 2, 5, 3
• Peripheral and central venous access 1, 5
• Urinary catheter for strict output monitoring 1, 5
• Nasogastric tube 1, 5
• Regular arterial blood gas analysis to detect hypoxia and acidosis 5
• Maintain strict asepsis with all invasive monitoring to prevent infection in pancreatic necrosis 5

Specialist Referral

Every hospital receiving acute admissions should have a single nominated clinical team to manage all pancreatitis patients. 1, 2, 5

Management in or referral to a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or other complications requiring interventional radiologic, endoscopic, or surgical procedures. 1, 2, 5

• A multidisciplinary team including intensivists, surgeons, gastroenterologists, and radiologists should individualize surgical treatment 3

Critical Pitfalls to Avoid

• Never delay drainage of infected collections—this leads to sepsis and increased mortality 5
• Never use prophylactic antibiotics routinely in mild cases 1, 2, 5
• Never delay enteral nutrition unnecessarily 5
• Never perform early surgical intervention when conservative management is possible 3
• Never use aggressive fluid resuscitation with normal saline—use goal-directed therapy with lactated Ringer's 2, 4
• Never delay cholecystectomy beyond two weeks in biliary pancreatitis 1, 2