What is the treatment for acute pancreatitis?

Treatment for Acute Pancreatitis

Immediate Severity Classification and Triage

The first critical step is to classify pancreatitis as mild (80% of cases) or severe (20% of cases) immediately upon presentation, as this determines the entire treatment approach—severe disease carries 95% of mortality and requires intensive care, while mild disease has <5% mortality and needs only supportive measures on a general ward 1, 2.

Management of Mild Acute Pancreatitis

Setting and Monitoring

• Manage on a general medical ward with basic vital sign monitoring 1, 2
• Establish peripheral venous access for fluid administration 1
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 2, 3

Fluid Resuscitation

• Use Lactated Ringer's solution for goal-directed moderate fluid resuscitation rather than normal saline or aggressive resuscitation 2, 3
• Target urine output >0.5 mL/kg body weight 2, 3
• Lactated Ringer's solution reduces systemic inflammatory response syndrome (SIRS) by 84% at 24 hours compared to normal saline (0% reduction), and significantly lowers C-reactive protein levels (51.5 vs 104 mg/dL) 4
• Recent meta-analysis demonstrates Lactated Ringer's reduces moderate-to-severe pancreatitis risk by 31%, mortality by 62%, and both systemic and local complications 5

Nutrition

• Initiate oral feeding immediately rather than keeping patients NPO 2, 3
• Advance regular diet as tolerated with appropriate pain management 1, 2

Pain Management

• Use Dilaudid as preferred opioid over morphine or fentanyl in non-intubated patients 2, 3
• Consider epidural analgesia as adjunct in multimodal approach for severe pain 2, 3

Antibiotics

• Do NOT use prophylactic antibiotics in mild pancreatitis—there is no evidence of benefit 1, 2, 3

Imaging

• Routine CT scanning is unnecessary unless clinical deterioration occurs 1, 2, 3

Management of Severe Acute Pancreatitis

Setting and Monitoring

• All severe cases must be managed in high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support 1, 2, 3
• Establish central venous line for fluid administration and CVP monitoring 1, 2
• Place urinary catheter and nasogastric tube 1, 2
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 2

Fluid Resuscitation

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution, NOT aggressive resuscitation 2, 3
• Target urine output >0.5 mL/kg body weight 2, 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 2, 3
• Early aggressive fluid therapy in predicted severe disease may be futile and deleterious 6

Nutritional Support

• Attempt enteral nutrition first via nasogastric or nasoenteral tube if oral feeding not tolerated 2, 3
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 2

Antibiotics

• Consider prophylactic antibiotics in severe acute pancreatitis with evidence of pancreatic necrosis >30% 2, 3
• Limit duration to maximum 14 days 2
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 2, 3

Imaging

• Perform dynamic CT scanning with non-ionic contrast within 3-10 days of admission 1, 2, 3
• Follow-up CT scans only if clinical status deteriorates or fails to show continued improvement 1

Management of Pancreatic Necrosis

• Perform image-guided fine needle aspiration 7-14 days after onset for patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis 2, 3
• Patients with infected necrosis (40% mortality) require intervention to completely debride all cavities containing necrotic material 2, 3

Management of Gallstone Pancreatitis

Timing and Indications for ERCP

• Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct 2, 3
• If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 1, 2
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 1, 2
• Always perform ERCP under antibiotic cover 1, 2, 3
• All patients undergoing early ERCP require endoscopic sphincterotomy whether or not stones are found 3

Critical Pitfalls to Avoid

• Do not use routine antibiotics in mild pancreatitis 1, 3
• Do not delay ERCP in severe gallstone pancreatitis with cholangitis 1, 3
• Do not use aggressive fluid resuscitation instead of goal-directed moderate resuscitation 3, 6
• Do not keep patients NPO when they can tolerate oral feeding 3
• Do not overuse CT scanning in mild cases with clinical improvement 3
• Do not fail to provide adequate nutritional support 1, 3