From the Guidelines
Patients with severe acute pancreatitis should be managed according to the 2019 WSES guidelines, which emphasize the importance of early fluid resuscitation, pain management, and early oral feeding, as well as the identification and treatment of infected necrosis and organ failure. The management of pancreatitis is crucial to prevent complications and reduce mortality rates, which can be as high as 15% in severe cases 1. The 2012 revision of the Atlanta classification and definitions is the most commonly used classification system for acute pancreatitis, which identifies two phases (early and late) and classifies severity as mild, moderate, or severe 1.
Some key points to consider in the management of pancreatitis include:
- Early fluid resuscitation to prevent dehydration and organ failure
- Pain management with medications such as morphine or hydromorphone
- Early oral feeding to promote recovery and prevent malnutrition
- Identification and treatment of infected necrosis and organ failure, which can be associated with high mortality rates 1
- Monitoring for complications such as pseudocysts, infection, bleeding, and diabetes due to pancreatic damage
The treatment of chronic pancreatitis focuses on pain management, enzyme replacement therapy, and lifestyle modifications, including complete alcohol cessation and smoking cessation 1. Severe cases may require endoscopic or surgical interventions. The mortality rate in patients with infected necrosis and organ failure can be as high as 35.2%, while concomitant sterile necrosis and organ failure is associated with a mortality of 19.8% 1. Therefore, early recognition and treatment of pancreatitis are essential to prevent complications and reduce mortality rates.
From the Research
Definition and Diagnosis of Pancreatitis
- Acute pancreatitis is a common condition that affects patients with varying degrees of severity and may lead to significant morbidity and mortality 2.
- The diagnosis of acute pancreatitis requires two of upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 3.
- Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated in the diagnosis of acute pancreatitis 3.
Management of Acute Pancreatitis
- Initial management of acute pancreatitis should focus on fluid resuscitation, with some data to support Ringer's lactate over physiological saline 2.
- Early oral feeding should be encouraged, not avoided, and use of parenteral nutrition is discouraged 2.
- Routine use of prophylactic antibiotics in acute pancreatitis is not recommended, nor is urgent endoscopic retrograde cholangiopancreatography in the absence of concomitant acute cholangitis 2.
- Cholecystectomy during the same admission of biliary pancreatitis should be performed in order to prevent future acute pancreatitis episodes 2.
- Patients with acute pancreatitis secondary to alcohol should receive alcohol counseling 2.
Treatment of Complications
- Infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy 4.
- Surgical necrosectomy is the traditional approach, but less invasive techniques (retroperitoneal or laparoscopic necrosectomy, computed tomography-guided percutaneous catheter drainage) may be equally effective 4.
- Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy 3.
Prevention of Recurrence
- Prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients 3.
- The impact of acute pancreatitis can be devastating, so management should be tailored to the individual patient's needs 3.
Scoring Systems
- Several scoring systems including the Revised Atlanta Criteria, the Bedside Index for Severity in Acute Pancreatitis score, and the American Association for the Surgery of Trauma grade have been devised to classify and predict the development of severe acute pancreatitis 5.