From the Guidelines
The management of acute pancreatitis should prioritize early enteral nutrition, aggressive intravenous fluid resuscitation, and pain control with opioid analgesics, while reserving antibiotics for confirmed infection or necrotizing pancreatitis with clinical deterioration, as recommended by the most recent guidelines 1.
Diagnosis and Management
Acute pancreatitis is diagnosed through a combination of clinical presentation, laboratory tests, and imaging studies. Diagnosis requires at least two of three criteria: characteristic abdominal pain, elevated serum lipase or amylase (at least three times the upper limit of normal), and supportive imaging findings.
Key Components of Management
- Aggressive intravenous fluid resuscitation using lactated Ringer's solution at 5-10 mL/kg/hr in the first 24 hours, with reassessment every 6-12 hours.
- Pain control should be achieved with opioid analgesics such as hydromorphone 0.5-1 mg IV every 4-6 hours or morphine 2-4 mg IV every 4 hours.
- Early enteral nutrition within 24-48 hours is recommended, preferably via oral route if tolerated, or nasogastric/nasojejunal feeding if not.
- Antibiotics are not routinely indicated unless there is confirmed infection or necrotizing pancreatitis with clinical deterioration, in which case imipenem 500 mg IV every 6 hours or meropenem 1 gram IV every 8 hours may be used.
- Severity assessment using scoring systems like BISAP or APACHE-II should be performed on admission and serially to identify patients at risk for complications.
- Endoscopic retrograde cholangiopancreatography (ERCP) is indicated within 24 hours for patients with acute cholangitis or biliary obstruction, as supported by earlier guidelines 1 but with an emphasis on the most current recommendations 1.
Underlying Pathophysiology
The underlying pathophysiology involves premature activation of pancreatic enzymes within the gland, leading to autodigestion and inflammation, which explains the importance of supportive care while the inflammatory process resolves, as discussed in the context of acute and chronic pancreatitis management 1.
Recent Guidelines
Recent guidelines from 2024 1 emphasize the importance of enteral nutrition, IV pain medications, early fluid resuscitation, and mechanical ventilation in the management of severe acute pancreatitis, while also highlighting the role of procalcitonin (PCT) and CT- or EUS-guided fine-needle aspiration (FNA) for diagnosing infected necrosis.
Key Considerations
- The management approach should be tailored to the severity of the disease, with severe cases requiring more intensive support and monitoring.
- The use of prophylactic antibiotics is not recommended for all patients with acute pancreatitis, as it is not associated with a significant decrease in mortality or morbidity, according to the most recent recommendations 1.
From the Research
Diagnosis of Acute Pancreatitis
- The diagnosis of acute pancreatitis requires two of the following criteria: upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 2, 3.
- Initial investigation includes serum amylase and lipase analysis, a lipid panel including triglycerides, analysis of immunoglobulins, a full blood count, electrolyte analysis, a hemoglobin A1c test, a complete metabolic panel, and transabdominal ultrasound 2, 3.
- Scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity and mortality 4.
Management of Acute Pancreatitis
- Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy 2, 3.
- Early oral feeding is encouraged if tolerated; if not, liquid supplement provision or enteral tube feeding within 48 h of admission has shown better outcomes 3.
- Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care 5.
- The type of fluid used for resuscitation in acute pancreatitis may affect the outcome, with lactated Ringer's potentially having a survival benefit over isotonic saline in critically-ill patients 6.
Complications and Follow-up
- Complications of acute pancreatitis include necrosis, infection, insulin resistance leading to diabetes mellitus, and pancreatic exocrine insufficiency requiring enzyme supplementation 2, 3.
- Patients need to attend regular follow-ups and abstain from alcohol and smoking (if warranted) to prevent the recurrence of acute pancreatitis 3.
- The mortality rate of acute pancreatitis has decreased in the past few decades due to better management skills, but the recent rise in acute pancreatitis episodes is concerning 3.