What is pancreatitis (inflammation of the pancreas)?

From the Guidelines

Pancreatitis should be managed based on its severity, with severe cases requiring intensive care and treatment of complications, as the mortality rate can be as high as 35.2% in patients with infected necrosis and organ failure, as noted in the 2019 WSES guidelines 1. The management of pancreatitis involves supportive care, pain management, and treatment of complications. The severity of pancreatitis can be classified using the Revised Atlanta Classification and Determinant-based Classification of Acute Pancreatitis Severity, which are similar in establishing the diagnosis and severity of acute pancreatitis 1.

• Key points in management include:
  • Antibiotics are always recommended to treat infected severe acute pancreatitis, with the diagnosis being challenging due to the clinical picture that cannot be distinguished from other infectious complications or from the inflammatory status caused by acute pancreatitis 1.
  • Serum measurements of procalcitonin (PCT) may be valuable in predicting the risk of developing infected pancreatic necrosis, as demonstrated in several studies 1.
  • Patients with persistent organ failure with infected necrosis have the highest risk of death, and should be admitted to an intensive care unit whenever possible 1.
  • Treatment of complications like pseudocysts or necrosis is crucial in severe cases, with CT-guided fine-needle aspiration (FNA) for Gram stain and culture being a diagnostic tool to guide antibiotic therapy, although its routine use has been abandoned in some centers due to high false negative findings 1. In terms of prevention, addressing underlying causes such as avoiding alcohol, treating gallstones, managing triglycerides, and controlling blood sugar in diabetics is essential. Chronic pancreatitis may require pancreatic enzyme supplements and sometimes pain management programs.
• The use of medications like morphine or hydromorphone for pain management, and bowel rest are also important aspects of treatment, with the goal of reducing morbidity, mortality, and improving quality of life, as supported by the 2019 WSES guidelines for the management of severe acute pancreatitis 1.

From the Research

Definition and Causes of Pancreatitis

• Pancreatitis is an inflammatory process of the pancreas with variable involvement of regional tissues and remote organs 2.
• The pathophysiologic hallmark of acute pancreatitis is the premature activation of trypsin, which leads to massive pancreas inflammation, systemic overproduction of pro-inflammatory mediators and ultimately remote organ dysfunction 2.
• Eighty percent of acute pancreatitis episodes are related either to gallstones or to alcohol abuse 2.
• Other causes of pancreatitis include hypertriglyceridaemia and drugs 3.

Diagnosis of Pancreatitis

• The diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels and/or characteristic findings on computed tomography 2.
• Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated in the diagnosis of pancreatitis 3.
• Abdominal cross-sectional imaging is undertaken to detect complications, such as if C-reactive protein exceeds 150 mg/L, or rarer aetiologies 3.

Treatment of Pancreatitis

• Initial priorities in the treatment of pancreatitis are intravenous fluid resuscitation, analgesia, and enteral nutrition 3.
• Vigorous fluid resuscitation and supplemental oxygen therapy are recommended, with enteral nutrition preferred over parenteral nutrition 2.
• Lactated Ringer's solution is associated with an anti-inflammatory effect in patients with acute pancreatitis 4.
• Aggressive hydration with lactated Ringer's solution is the best approach to intravenous hydration for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis 5.
• Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy 3.

Management and Prevention

• Early management is essential to identify and treat patients with pancreatitis to prevent complications 6.
• Nutrition plays an important role in treating patients with pancreatitis, with the safety of early refeeding and importance in preventing complications addressed in guidelines 6.
• Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis 6.