What is the management approach for pancreatitis?

Management of Acute Pancreatitis

Initial Triage and Severity Assessment

All patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high-dependency unit (HDU) with full monitoring and organ support. 1, 2

• Complete severity stratification within 48 hours using 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 follows 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

Fluid Resuscitation Strategy

Use lactated Ringer's solution at a moderate rate rather than aggressive hydration with normal saline. 4, 5

• Target urine output >0.5 ml/kg body weight 1, 2
• Lactated Ringer's solution reduces systemic inflammatory response syndrome (SIRS) by 84% compared to normal saline and significantly lowers C-reactive protein levels (51.5 vs 104 mg/dL) 5
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2, 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate regularly to assess tissue perfusion 1, 2

Monitoring Requirements

Severe cases require peripheral venous access plus central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube. 1

• Hourly vital signs: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1, 2
• Regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical assessment alone 2
• Maintain strict asepsis with invasive monitoring equipment as these serve as sources of subsequent sepsis 2

Pain Management

Dilaudid is preferred over morphine or fentanyl in non-intubated patients. 1, 2

• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach for moderate to severe pain 1, 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1, 2
• Avoid NSAIDs in acute kidney injury 1, 2

Nutritional Support

Initiate early enteral nutrition within 24 hours rather than total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2, 4

• Both gastric (nasogastric) and jejunal (nasojejunal) feeding can be delivered safely with no difference in outcomes 1, 2
• Early enteral nutrition should be initiated even in severe cases 1, 2
• TPN should be avoided, but partial parenteral nutrition 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. 2, 3, 4

• In severe acute pancreatitis with pancreatic necrosis, the evidence for prophylactic antibiotics is conflicting and there is no consensus 6, 1, 2
• If prophylactic antibiotics are used in severe cases, intravenous cefuroxime is a reasonable balance between efficacy and cost, given for a maximum of 14 days 6, 1, 2
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1, 2
• ERCP should always be performed under antibiotic cover 2

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. 6, 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 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 6, 1, 2
• For mild gallstone pancreatitis, perform laparoscopic cholecystectomy within two to four weeks, preferably during the same hospital admission to prevent recurrent pancreatitis 2
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission unless a clear plan exists for treatment within two weeks 6

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. 2, 3

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 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 for debridement of infected necrosis before open surgical necrosectomy. 2, 3

• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 6
• Infected necrosis is the most serious local complication with 40% mortality rate 1, 2
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 6, 2, 3
• 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

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. 6, 1, 2, 3

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 6, 1, 2, 3
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2, 3
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team 1, 2

Pharmacological Treatment

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

• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1, 2

Common Pitfalls to Avoid

• Using aggressive hydration with normal saline instead of moderate resuscitation with lactated Ringer's solution increases systemic inflammation 5
• Administering prophylactic antibiotics routinely in mild cases provides no benefit 2, 3, 4
• Delaying ERCP beyond 72 hours in severe gallstone pancreatitis with cholangitis worsens outcomes 6, 2
• Using hydroxyethyl starch fluids increases risk of multiple organ failure 2, 3
• Failing to refer patients with >30% necrosis to specialist centers delays appropriate intervention 6, 2, 3