What are the guidelines for medical management of acute pancreatitis?

Acute Pancreatitis: Medical Management Guidelines

Diagnosis

Diagnose acute pancreatitis when two of three criteria are present: characteristic abdominal pain, serum amylase/lipase ≥3× upper limit of normal, and/or imaging findings consistent with pancreatitis. 1, 2

• Lipase is preferred over amylase for diagnosis when available 1
• Diagnosis should be established within 48 hours of admission 1
• Contrast-enhanced CT should be reserved for diagnostic uncertainty or clinical deterioration, not routine initial diagnosis 2, 3
• Determine etiology in at least 80% of cases; no more than 20% should remain idiopathic 1

Severity Assessment

Stratify severity within 48 hours using clinical impression, obesity, APACHE II score in first 24 hours, CRP >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours. 1

• Use Atlanta criteria definitions, but organ failure resolving within 48 hours should not classify disease as severe 1
• Patients with persisting organ failure, sepsis signs, or clinical deterioration at 6-10 days require CT imaging 1

Initial Resuscitation and Monitoring

All patients with severe acute pancreatitis must be managed in HDU/ICU with full monitoring including hourly vital signs (pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature). 1, 4

• Provide aggressive intravenous hydration with lactated Ringer's solution, most beneficial within first 12-24 hours 2, 5
• Establish peripheral IV access at minimum; severe cases require central venous line, urinary catheter, and nasogastric tube 1, 4
• Swan-Ganz catheter indicated for cardiocirculatory compromise or failed initial resuscitation 1
• Monitor hematocrit, BUN, creatinine, and lactate as tissue perfusion indicators 4

Pain Management

Use multimodal analgesia; NSAIDs with acetaminophen for mild pain, weak opioids for moderate pain, and consider epidural analgesia for severe pain requiring high-dose opioids. 4, 5

• Always prescribe laxatives when using opioids to prevent constipation 6
• Avoid NSAIDs in patients with acute kidney injury 4

Nutritional Support

Initiate early enteral nutrition (within 24 hours if tolerated) via nasogastric or nasojejunal route; both are equally effective. 1, 4, 2

• In mild pancreatitis, start oral feeding immediately if no nausea/vomiting 2, 7
• Enteral nutrition is strongly preferred over parenteral nutrition to prevent infectious complications 1, 4, 2
• Nasogastric feeding is effective in 80% of cases 1
• Reserve parenteral nutrition only for patients who cannot tolerate enteral feeding 4, 2

Antibiotic Management

Do not routinely administer prophylactic antibiotics in mild or severe acute pancreatitis with sterile necrosis. 1, 4, 2

• The evidence on antibiotic prophylaxis for pancreatic necrosis is conflicting with no consensus 1
• If prophylactic antibiotics are used, limit to maximum 14 days 1
• Use antibiotics only for documented specific infections (respiratory, urinary, cholangitis, line-related) 1, 4
• In infected necrosis, antibiotics penetrating pancreatic tissue may delay intervention and reduce mortality 2

Management of Gallstone Pancreatitis

Perform urgent ERCP within 24 hours in patients with acute pancreatitis and concurrent cholangitis, jaundice, or dilated common bile duct. 1, 4, 2

• ERCP is best performed within 72 hours of pain onset 4
• All patients with biliary pancreatitis must undergo definitive gallstone management (cholecystectomy) during the same admission or within 2 weeks 1, 4, 6
• Use pancreatic duct stents and/or rectal NSAID suppositories to reduce post-ERCP pancreatitis risk in high-risk patients 2

Management of Pancreatic Necrosis

Obtain CT scanning at 6-10 days (not routinely earlier) in patients with persistent organ failure, sepsis signs, or clinical deterioration. 1

• Sterile necrosis does not require intervention; manage conservatively with supportive care 4, 2
• Patients with >30% necrosis and persistent symptoms, or suspected infected necrosis, require image-guided fine needle aspiration 1, 4
• Delay intervention for infected necrosis until at least 4 weeks when possible to allow wall formation 4, 2
• Use step-up approach: start with percutaneous/endoscopic drainage, progress to minimally invasive necrosectomy only if no improvement 4
• Patients with infected necrosis require complete debridement of all necrotic material 1, 4

Interventions to Avoid

Do not use aprotinin, glucagon, somatostatin, fresh frozen plasma, or peritoneal lavage—none have proven benefit. 1

• Do not perform routine CT scanning in mild pancreatitis without clinical deterioration 1
• Avoid aggressive fluid protocols beyond 24 hours as they increase mortality without benefit 4

Referral Criteria

Refer patients with extensive necrotizing pancreatitis or complications requiring ITU care, interventional radiology, endoscopy, or surgery to specialist centers. 1, 4, 6

• Every hospital receiving acute admissions should have a designated clinical team for pancreatitis management 1, 4
• Specialist centers should have 24-hour access to contrast-enhanced CT/MRI, percutaneous drainage, and ERCP 1

Audit Standards

• Overall mortality should be <10%; <30% in severe pancreatitis 1
• Mortality from necrotizing pancreatitis is 30-40% overall, with specialist centers achieving 10-20% 4