What is the treatment for acute pancreatitis?

Treatment for Acute Pancreatitis

The treatment of acute pancreatitis is severity-dependent: severe cases require ICU/HDU management with goal-directed fluid resuscitation using Lactated Ringer's solution, immediate oral feeding when tolerated, and selective interventions for complications, while mild cases need only general ward supportive care with early oral feeding and pain control. 1, 2

Initial Severity Assessment and Triage

Immediately classify pancreatitis as mild versus severe upon diagnosis, as this determines the entire treatment pathway. 3

• Severe disease accounts for only 20% of cases but carries 95% of mortality, while mild disease represents 80% of cases with <5% mortality 1, 3
• Use clinical impression, obesity, APACHE II score in first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours to predict severity 4
• All severe cases must be managed in HDU or ICU with full monitoring and systems support 4, 1, 2
• Mild cases can be managed on general medical ward with basic vital sign monitoring 2, 3

Fluid Resuscitation Strategy

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution, NOT aggressive fluid resuscitation. 1, 2

• 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
• Establish central venous line for CVP monitoring in severe cases 3
• Aggressive fluid resuscitation is specifically discouraged 2

Nutritional Management

Initiate oral feeding immediately rather than keeping patients NPO—this represents a paradigm shift from traditional practice. 1, 2

• Advance regular diet as tolerated with appropriate pain management 1, 2
• If oral feeding not tolerated, use enteral nutrition via nasogastric tube (effective in 80% of cases) or nasoenteral tube 4, 2, 3
• Nasogastric route is as effective as nasojejunal route 4
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 3

Pain Management

Use Dilaudid as the preferred opioid over morphine or fentanyl in non-intubated patients. 1, 2

• Consider epidural analgesia as adjunct in multimodal approach for severe pain 1, 2
• Pain control should be a clinical priority 2

Antibiotic Strategy

Do NOT use prophylactic antibiotics in mild pancreatitis or routine biliary pancreatitis. 1, 2, 3

• Consider prophylactic antibiotics only in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 2, 3
• If antibiotics are used, limit duration to maximum 14 days 4, 1
• Intravenous cefuroxime represents reasonable balance between efficacy and cost 2, 3
• This recommendation differs from older practices that favored routine antibiotic prophylaxis 4

Monitoring Requirements

For Severe Cases:

• Establish peripheral venous access, central venous line, urinary catheter, and nasogastric tube 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
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 2, 3

For Mild Cases:

• Basic vital sign monitoring with continuous oxygen saturation monitoring 2, 3
• Supplemental oxygen to maintain saturation >95% 2

Imaging Strategy

Perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days of admission for severe cases to identify pancreatic necrosis. 1, 2, 3

• Obtain CT for patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 4, 1
• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 2, 3
• Non-ionic contrast must be used in all cases 2, 3

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 4, 1, 2, 3

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 4, 2
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 4
• Always perform ERCP under antibiotic cover 3
• If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 3
• 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 4, 1

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 of necrosis and clinical suspicion of sepsis. 1, 2, 3

• FNA accuracy is reported to be 89-100% for diagnosing infected necrosis 5
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 4, 1, 2, 3
• Infected necrosis carries 40% mortality 2
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 4, 1
• Sterile pancreatic necrosis should be managed conservatively 5
• Necrosectomy should be performed as late as possible when indicated 5

Referral Criteria

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or complications requiring ICU care, or interventional radiological, endoscopic, or surgical procedures. 4

• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 4

Critical Pitfalls to Avoid

• Do NOT use aggressive fluid resuscitation—use goal-directed moderate resuscitation 2
• Do NOT keep patients NPO when they can tolerate oral feeding 2
• Do NOT use routine prophylactic antibiotics in mild pancreatitis 2
• Do NOT delay ERCP in severe gallstone pancreatitis with cholangitis 2
• Do NOT overuse CT scanning in mild cases with clinical improvement 2
• Do NOT use morphine or fentanyl as first-line opioids—use Dilaudid 1, 2