What is the treatment for pancreatitis?

Treatment of Acute Pancreatitis

Immediate Severity Classification and Triage

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

• Severe acute pancreatitis (20% of cases) must be managed in a high dependency unit or intensive care unit with full monitoring including central venous line, urinary catheter, nasogastric tube, and continuous vital sign monitoring 3, 1
• Mild acute pancreatitis (80% of cases) can be managed on a general medical ward with basic vital sign monitoring and peripheral venous access 1, 2

Fluid Resuscitation Strategy

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive resuscitation or normal saline. 1, 2, 4

• Lactated Ringer's solution reduces severity by 31%, mortality by 62%, need for intensive care by 50%, organ failure by 22%, and local complications by 36% compared to normal saline 4
• Target urine output >0.5 ml/kg body weight 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1, 2
• Maintain oxygen saturation >95% with supplemental oxygen 1, 2

Critical pitfall: Aggressive fluid resuscitation in severe disease may be futile and deleterious, while moderate resuscitation shows better outcomes 5, 6

Nutritional Management

Initiate oral feeding immediately in mild pancreatitis and advance regular diet as tolerated—do not keep patients NPO. 1, 2

• For severe pancreatitis requiring nutritional support, use enteral nutrition first via nasogastric or nasoenteral tube (effective in 80% of cases) 3, 1, 7
• Reserve parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 1

Pain Management

Use Dilaudid as the preferred opioid over morphine or fentanyl in non-intubated patients. 1

• Consider epidural analgesia as adjunct in multimodal approach for severe pain 1, 2

Antibiotic Therapy

Do not use prophylactic antibiotics in mild pancreatitis or routine biliary pancreatitis—there is no evidence of benefit. 1, 2, 7

• Consider prophylactic antibiotics only in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 7
• If antibiotics are used, limit duration to maximum 14 days 3, 7
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 3, 2

Critical caveat: The evidence on antibiotic prophylaxis remains conflicting with no clear consensus 3, 7

Imaging Strategy

Perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days only in severe cases or when clinical deterioration occurs. 3, 2, 7

• Routine CT scanning is unnecessary in mild cases with clinical improvement 2, 7
• Patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission require CT imaging 3, 7

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 3, 1, 7

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 3, 2
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 3, 7
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission 3, 7

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. 1, 7

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 3, 1, 7
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 3, 7

Monitoring Requirements for Severe Cases

• Establish peripheral venous access, central venous line for CVP monitoring, urinary catheter, and nasogastric tube with strict asepsis 3
• Monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 3
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 3