What is the treatment for pancreatitis?

Treatment of Acute Pancreatitis

Severity-Based Treatment Algorithm

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support, while mild cases can be managed on a general medical ward with basic supportive care. 1, 2

The treatment approach is fundamentally determined by severity classification, as severe disease carries 95% of mortality despite representing only 20% of cases, while mild disease accounts for 80% of cases with less than 5% mortality. 2, 3

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Initial Management for Mild Acute Pancreatitis

Monitoring and Setting

• Manage on general medical ward with basic vital sign monitoring and peripheral venous access 2, 4
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 2, 4

Fluid Resuscitation

• Use Lactated Ringer's solution for goal-directed moderate fluid resuscitation rather than aggressive resuscitation 2, 4
• Target urine output >0.5 ml/kg body weight 2, 4
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 2, 4

Nutrition

• Initiate oral feeding immediately rather than keeping patients NPO 2, 4
• Advance regular diet as tolerated with appropriate pain management 2, 4

Pain Management

• Use Dilaudid as preferred opioid over morphine or fentanyl in non-intubated patients 2, 4
• Consider epidural analgesia as adjunct in multimodal approach for severe pain 2, 4

Antibiotics

• Do not use prophylactic antibiotics in mild pancreatitis - there is no evidence of benefit 2, 4, 3

Imaging

• Routine CT scanning is unnecessary unless clinical deterioration occurs 4, 3

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Management of Severe Acute Pancreatitis

Critical Care Setting

• Establish central venous line for fluid administration and CVP monitoring 2, 4
• Place urinary catheter and nasogastric tube 1, 2
• Observe strict asepsis with all invasive monitoring equipment as these may serve as sources of subsequent sepsis 1
• Monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1, 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 1, 2

Fluid Resuscitation

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution 2, 4
• Target urine output >0.5 ml/kg body weight 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate 2, 4

Common Pitfall: Aggressive fluid resuscitation is no longer recommended - moderate, goal-directed resuscitation has better outcomes. 5

Nutritional Support

• Attempt enteral nutrition first via nasogastric or nasoenteral tube if oral feeding not tolerated 2, 4
• The nasogastric route is effective in 80% of cases 1, 3
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 2, 4
• If ileus persists for more than 5 days, parenteral nutrition will be required 1

Important Caveat: Exercise caution when administering nasogastric feed to patients with impaired consciousness due to aspiration risk. 1

Antibiotic Prophylaxis

The evidence on antibiotic prophylaxis remains conflicting. 1, 3

• If prophylactic antibiotics are used in severe pancreatitis with evidence of pancreatic necrosis >30%, limit duration to maximum 14 days 1, 2, 3
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 1, 2, 4

Evidence Note: Pooled data from trials shows significantly fewer infections and deaths in patients treated with antibiotics, though individual trials show mixed results. 1

Imaging

• Perform dynamic CT scanning with non-ionic contrast within 3-10 days of admission 1, 2, 4
• Obtain CT for patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 1, 3

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Management of Gallstone Pancreatitis

Urgent ERCP Indications

Perform urgent therapeutic ERCP within 72 hours in patients with:

• Severe gallstone pancreatitis 1, 2, 4, 3
• Cholangitis 1, 2, 4, 3
• Jaundice 1, 2, 4, 3
• Dilated common bile duct 1, 2, 4, 3

ERCP Protocol

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1, 4
• Always perform ERCP under antibiotic cover 1, 2
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 1

Critical Timing: If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy. 1, 2

Definitive Management

• 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 1, 3

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Management of Pancreatic Necrosis

Assessment

• Perform image-guided fine needle aspiration 7-14 days after onset for patients with:
  • Persistent symptoms and >30% pancreatic necrosis 1, 2, 4, 3
  • Smaller areas of necrosis with clinical suspicion of sepsis 1, 2, 4, 3

Intervention

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2, 4, 3
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1, 3
• Delay necrosectomy as long as possible - later intervention is associated with fewer procedures 5

Important Note: Infected necrosis carries 40% mortality and requires aggressive management. 4

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Key Pitfalls to Avoid

• Never routinely use antibiotics in mild pancreatitis - no proven benefit 2, 4, 3
• Never delay ERCP in severe gallstone pancreatitis with cholangitis - immediate intervention required 2, 4, 3
• Never keep patients NPO when they can tolerate oral feeding - immediate feeding improves outcomes 4
• Never use aggressive fluid resuscitation - goal-directed moderate resuscitation is superior 4, 5
• Never overuse CT scanning in mild cases with clinical improvement - imaging should be targeted 4, 3