What is the treatment for acute pancreatitis?

Treatment of Acute Pancreatitis

Initial Management: Severity-Stratified Approach

All patients with acute pancreatitis require immediate aggressive intravenous fluid resuscitation, fasting, and pain control, with treatment intensity determined by severity assessment within the first 24-48 hours. 1

Fundamental Care for All Patients

• Initiate aggressive IV fluid replacement immediately upon diagnosis to prevent hypovolemia and organ failure 1, 2
• Enforce strict fasting (NPO status) until pain and nausea resolve in mild cases 2, 3
• Provide adequate analgesia for pain control 4, 5
• Monitor vital signs closely: pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature 1, 5

Severity Assessment (Within 24-48 Hours)

• Use APACHE II score, clinical impression of severity, or obesity assessment within the first 24 hours 1
• Measure C-reactive protein at 48 hours (>150 mg/L indicates severe disease) or calculate Glasgow score (≥3 indicates severity) 1
• Identify persisting organ failure beyond 48 hours as the key indicator of severe acute pancreatitis 1

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Mild Acute Pancreatitis (80% of Cases)

Conservative Management

• Continue fundamental medical treatment with IV fluids, fasting, and analgesia until symptoms resolve 4, 6
• Resume oral feeding once abdominal pain, nausea, and vomiting have subsided—no need to wait for normalized laboratory values 2, 3
• No routine CT scanning is necessary unless clinical deterioration occurs 1
• No antibiotic prophylaxis is indicated for mild disease 1

Gallstone-Specific Management in Mild Disease

• Perform cholecystectomy during the same hospital admission or within 2 weeks of discharge to prevent recurrent pancreatitis 1
• Do not delay definitive gallstone treatment beyond 2 weeks, as this exposes patients to risk of potentially fatal recurrent attacks 1

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Severe Acute Pancreatitis (20% of Cases)

Critical Care Setting

All patients with severe acute pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and organ support systems. 1

Intensive Monitoring Requirements

• Establish peripheral and central venous access for fluid administration and CVP monitoring 1
• Insert urinary catheter and nasogastric tube with strict aseptic technique 1
• Consider Swan-Ganz catheter if initial resuscitation fails or cardiocirculatory compromise exists, to measure pulmonary artery wedge pressure, cardiac output, and systemic resistance 1
• Perform hourly nursing assessments including pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature, and cumulative fluid balance 1

Fluid Resuscitation

• Administer large-volume IV fluid replacement (typically much higher volumes than mild cases) while constantly assessing circulatory dynamics 5
• Adjust fluid dosing based on CVP monitoring and clinical response to stabilize cardiovascular dynamics 5

Nutritional Support

• Initiate enteral nutrition within 48 hours of presentation if nutritional support is required 2, 3
• Use nasogastric route first—it is effective in 80% of cases and simpler than nasojejunal feeding 1
• Avoid total parenteral nutrition where possible, as enteral feeding reduces complications including death, multiorgan failure, and systemic infections 2, 3

Antibiotic Prophylaxis: Controversial but Commonly Used

The evidence on antibiotic prophylaxis remains conflicting—some trials show benefit, others do not, and there is no consensus 1. However:

• If using antibiotic prophylaxis, administer intravenous cefuroxime as a reasonable balance between efficacy and cost 1
• Limit prophylaxis to a maximum of 14 days 1
• Consider imipenem/cilastatin in cases with >30% necrosis to decrease pancreatic infection risk 3

Common pitfall: Avoid using central lines or invasive monitoring as sources of subsequent sepsis—maintain strict asepsis during placement and care 1

Imaging for Complications

• Obtain contrast-enhanced CT scan between 3-10 days after admission to assess for pancreatic necrosis 1
• Repeat CT if persistent organ failure, signs of sepsis, or clinical deterioration occur 6-10 days after admission 1

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Management of Pancreatic Necrosis

Suspected Infection

• Perform image-guided fine needle aspiration (FNA) for culture in patients with persistent symptoms and >30% necrosis, or those with smaller necrosis but clinical suspicion of sepsis, at 7-14 days after onset 1
• FNA has 89-100% accuracy for diagnosing infected necrosis 6

Infected Necrosis

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 1

• Delay necrosectomy as late as possible to allow demarcation of necrotic tissue 6
• Choose surgical technique (necrosectomy, percutaneous drainage, endoscopic approach) based on individual features and local expertise 1
• Consider non-surgical treatment with antibiotics if the patient's general condition remains stable, even with infected necrosis 6

Sterile Necrosis

• Continue non-surgical treatment for sterile pancreatic necrosis 6

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Gallstone Pancreatitis: Urgent ERCP Indications

Severe Gallstone Pancreatitis

Perform urgent therapeutic ERCP with sphincterotomy within 72 hours of pain onset in patients with suspected or proven gallstone etiology who have: 1

• Predicted or actual severe pancreatitis
• Cholangitis (fever, rigors, positive blood cultures)
• Jaundice
• Dilated common bile duct
• Failure to improve within 48 hours despite intensive resuscitation 1

ERCP Technique

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1
• Patients with cholangitis require immediate sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 1

Definitive Gallstone Management

• Delay cholecystectomy in severe cases until signs of lung injury and systemic disturbance have completely resolved 1
• Once stabilized, perform cholecystectomy during the same admission or within 2 weeks to prevent recurrent pancreatitis 1
• For unfit patients, endoscopic sphincterotomy alone is adequate definitive treatment 1

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Treatments WITHOUT Proven Benefit

Do not use aprotinin, glucagon, somatostatin, fresh frozen plasma, or peritoneal lavage—none have proven value in acute pancreatitis. 1