Management of Acute Pancreatitis
Severity Stratification and Initial Triage
All patients with acute pancreatitis must undergo severity stratification within 48 hours of admission to guide appropriate level of care and reduce mortality. 1, 2
Mild acute pancreatitis (80% of cases) can be managed on general wards with basic monitoring, while severe acute pancreatitis (20% of cases) requires ICU or HDU admission with full systems support. 1, 2
Use clinical impression, APACHE II score in first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persistent organ failure beyond 48 hours to identify severe disease 1, 2
Mortality is <5% in mild cases but approximately 15-30% in severe cases, with infected necrosis plus organ failure carrying 35.2% mortality 1, 2
Fluid Resuscitation
Moderate fluid resuscitation with lactated Ringer's solution is superior to aggressive resuscitation and normal saline, targeting urine output >0.5 ml/kg/hour without causing fluid overload. 3, 4
Start with 10 ml/kg bolus only if hypovolemic, then 1.5 ml/kg/hour maintenance—aggressive resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) increases fluid overload risk 2.85-fold without improving outcomes 3
Lactated Ringer's solution reduces systemic inflammatory response syndrome (SIRS) by 84% at 24 hours and lowers C-reactive protein compared to normal saline 5, 4
Avoid hydroxyethyl starch fluids as they increase multiple organ failure risk 2
Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion adequacy 2, 6
Monitoring Requirements
Mild cases require basic vital signs monitoring on general wards, while severe cases need invasive monitoring in ICU/HDU settings. 1
For mild pancreatitis: hourly temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and urine output 1
For severe pancreatitis: add central venous line for CVP monitoring, urinary catheter, nasogastric tube, and consider Swan-Ganz catheter if initial resuscitation fails 1
Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical examination alone 1
Maintain strict asepsis with all invasive lines as they become sources of sepsis in pancreatic necrosis 1
Pain Management
Aggressive pain control is a clinical priority—use dilaudid as first-line with patient-controlled analgesia, and consider epidural analgesia for refractory pain. 2, 7
Dilaudid is preferred over morphine or fentanyl in non-intubated patients 2, 7
Integrate patient-controlled analgesia (PCA) with every pain management strategy 2, 7
Epidural analgesia serves as alternative or adjunct in multimodal approach for moderate to severe pain 2, 7
Nutritional Support
Initiate early enteral nutrition via nasogastric route within 24 hours in mild cases and as soon as tolerated in severe cases—avoid total parenteral nutrition. 1, 2
Enteral nutrition prevents gut failure and infectious complications compared to TPN 1, 2
Nasogastric feeding is effective in 80% of cases and equally safe as jejunal feeding 1, 2
Early oral feeding within 24 hours is recommended in mild cases as tolerated 2
Reserve parenteral nutrition only if ileus persists beyond 5 days or enteral route completely fails 2, 7
Antibiotic Therapy
Do not give prophylactic antibiotics in mild acute pancreatitis—they provide no benefit and should only be used for documented infections. 1, 8
In severe necrotizing pancreatitis, evidence for prophylactic antibiotics is conflicting with no current consensus 1
If prophylactic antibiotics are used in severe cases, limit to maximum 14 days with intravenous cefuroxime as reasonable choice 1, 2
Use antibiotics when specific infections occur: pneumonia, urinary tract infection, cholangitis, or line-related sepsis 1, 2
Always perform ERCP under antibiotic cover 2
Management of Gallstone Pancreatitis
Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct—all require endoscopic sphincterotomy regardless of stone visualization. 1, 2
Severe gallstone pancreatitis with cholangitis (fever, rigors, positive blood cultures) requires immediate ERCP 2
Failure to improve within 48 hours despite intensive resuscitation indicates urgent ERCP and sphincterotomy 2
All patients undergoing early ERCP for severe gallstone pancreatitis require sphincterotomy whether or not stones are found 1
Perform definitive cholecystectomy during same hospital admission or within 2 weeks to prevent recurrent pancreatitis in mild gallstone cases. 1, 2
Imaging Strategy
Obtain contrast-enhanced CT scan at 3-10 days only in severe cases or when clinical deterioration occurs—routine CT is unnecessary in mild pancreatitis. 1, 2
Dynamic CT with non-ionic contrast identifies pancreatic necrosis extent and guides management in severe cases 2
Indications for CT include: persistent organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission 1
Repeat CT only if clinical status deteriorates or fails to show continued improvement 2, 7
Mild pancreatitis requires CT only with change in clinical status suggesting new complications 2, 7
Management of Infected Necrosis
Infected necrosis requires intervention with complete debridement—prioritize minimally invasive approaches before open surgical necrosectomy. 2, 7, 8
Infected necrosis is the most serious local complication with 40% mortality 2, 7
Perform image-guided fine needle aspiration in patients with >30% necrosis and persistent symptoms or clinical suspicion of sepsis 1
Consider minimally invasive debridement techniques before open necrosectomy 2, 8
Delaying drainage of infected collections leads to sepsis and increased mortality 2, 8
Specialist Care and Multidisciplinary Approach
Every hospital admitting acute pancreatitis patients must have a designated clinical team, with referral to specialist centers for extensive necrotizing pancreatitis (>30% necrosis) or complications requiring advanced interventions. 1, 2
Single nominated clinical team should manage all acute pancreatitis patients at each hospital 1, 8
Refer to specialist unit for extensive necrotizing pancreatitis or complications requiring ICU care, interventional radiology, endoscopy, or surgery 1, 2
Multidisciplinary team must include intensivists, surgeons, gastroenterologists, and radiologists 2, 8
Etiological Investigation
Determine etiology in at least 80% of cases within 48 hours—no more than 20% should remain idiopathic. 1
Early ultrasound for gallstones should be repeated if initially negative 8
Consider bile sampling for microlithiasis in patients with recurrent attacks and no identified cause 1
Common Pitfalls to Avoid
Avoid aggressive fluid resuscitation (>3 ml/kg/hour)—it causes fluid overload without improving outcomes 3
Do not use prophylactic antibiotics routinely in mild pancreatitis—they provide no benefit 1, 8
Do not delay ERCP beyond 72 hours in severe gallstone pancreatitis with cholangitis 1, 2
Do not use total parenteral nutrition when enteral route is tolerated—it increases infectious complications 1, 2
Do not delay drainage of infected necrosis—it increases sepsis and mortality 2, 8