What is the management of pancreatitis?

Management of Acute Pancreatitis

Severity Assessment and Initial Triage

All patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high-dependency unit (HDU) with full monitoring and systems support, while mild cases can be managed on general wards. 1, 2

• Complete severity stratification within 48 hours using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure lasting >48 hours 2, 3
• Mild acute pancreatitis (80% of cases) has <5% mortality and runs a self-limiting course 2, 3
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2, 3
• Infected necrosis with organ failure carries 35.2% mortality, while sterile necrosis with organ failure has 19.8% mortality 2, 3

Fluid Resuscitation

Initiate goal-directed fluid resuscitation immediately, targeting urine output >0.5 ml/kg body weight, using lactated Ringer's solution rather than normal saline. 1, 2, 4

• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2, 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess adequate tissue perfusion 1, 2
• Large doses of fluid replacement are usually required in severe cases, adjusted while constantly assessing circulatory dynamics 5

Monitoring Requirements

Mild Cases

• Monitor temperature, pulse, blood pressure, and urine output on general ward 6
• Peripheral intravenous line for fluids and possibly nasogastric tube 6
• Few patients warrant indwelling urinary catheter 6

Severe Cases

• Require peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 6, 1
• Regular hourly assessment of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 6, 1, 2
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 6, 2
• Swan-Ganz catheter required when cardiocirculatory compromise exists or initial resuscitation fails to produce clinical improvement 6
• Strict asepsis must be observed in placement and care of invasive monitoring equipment as these may serve as sources of subsequent sepsis in presence of pancreatic necrosis 6, 2

Pain Management

Use Dilaudid as the preferred opioid in non-intubated patients, and integrate patient-controlled analgesia (PCA) with every pain management strategy. 1, 2

• Pain control is a clinical priority requiring aggressive management 1, 2, 3
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 1, 2, 3
• Avoid NSAIDs in acute kidney injury 1, 2
• No evidence supports restrictions in pain medication 1

Nutritional Support

Initiate early enteral nutrition (within 24 hours in mild cases, even in severe cases) rather than total parenteral nutrition to prevent gut failure and infectious complications. 1, 2, 3

• Both gastric and jejunal feeding can be delivered safely 1, 2
• TPN should be avoided, but partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 1, 2
• If ileus persists for more than five days, parenteral nutrition will be required 1, 2

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis, as there is no evidence they improve outcomes or reduce septic complications. 6, 1, 2, 3

• In severe acute pancreatitis with evidence of pancreatic necrosis, prophylactic antibiotics may reduce complications and deaths, though evidence remains conflicting 6, 1, 2
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases if used 6, 2
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 6, 1, 2
• Duration of prophylactic treatment is unclear at present 6

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 1, 2, 3

• Severe gallstone pancreatitis with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) requires immediate therapeutic ERCP 6, 2
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 6, 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1, 2
• ERCP should always be performed under antibiotic cover 6, 2
• For mild gallstone pancreatitis, perform laparoscopic (or open) cholecystectomy within two to four weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 2

Imaging Strategy

Obtain dynamic CT scanning with non-ionic contrast within three to 10 days of admission in severe cases to identify pancreatic necrosis and guide management. 6, 1, 2

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 6, 1, 2, 3
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1, 2
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 1, 2

Management of Infected Necrosis

Consider minimally invasive approaches (endoscopic or percutaneous drainage) for debridement of infected necrosis before open surgical necrosectomy. 1, 2, 7

• Infected necrosis is the most serious local complication with a high mortality rate (40%) 1, 2
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 2, 3
• Dual modalities (endoscopic and percutaneous drainage) offer better outcomes with fewer complications 7
• Direct endoscopic necrosectomy is considered for patients who do not improve with drainage 7
• Delaying drainage of infected collections leads to sepsis and increased mortality 2, 3
• Local complications such as pseudocyst and pancreatic abscess often require surgical, endoscopic, or radiological intervention 1, 2

Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective in acute pancreatitis. 1, 2

• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1, 2
• Treatments including aprotonin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have no proven value and cannot be recommended 6

Specialist Care and Multidisciplinary Approach

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis, with referral to a specialist unit for extensive necrotizing pancreatitis (>30% necrosis) or complications. 1, 2, 3

• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2, 3, 7
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team 1, 2

Etiological Investigation

• The etiology should be determined in 75-80% of cases, with no more than 20-25% classified as "idiopathic" 6, 3
• Early ultrasound for gallstones should be repeated if initially negative 3

Common Pitfalls to Avoid

• Using prophylactic antibiotics routinely in mild cases provides no benefit 6, 1, 2, 3
• Delaying drainage of infected collections leads to sepsis and increased mortality 2, 3
• Using hydroxyethyl starch fluids increases risk of multiple organ failure 2, 3
• Failing to reassess severity within 48 hours can miss progression from mild to severe disease 2, 5