What is the treatment for acute pancreatitis?

Treatment for Acute Pancreatitis

Immediate Severity Classification and Triage

The first critical step is to classify pancreatitis as mild or severe immediately upon diagnosis, as this determines the entire treatment pathway—severe disease carries 95% of mortality and requires ICU-level care, while mild disease has <5% mortality and needs only supportive measures on a general ward 1, 2.

• 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 2
• Mild pancreatitis (80% of cases) can be managed on general medical ward with basic vital sign monitoring 1, 2
• Severe pancreatitis (20% of cases) must be managed in HDU or ICU with full monitoring including central venous line for CVP monitoring, urinary catheter, nasogastric tube, and regular arterial blood gas analysis 3, 1

Fluid Resuscitation Strategy

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive fluid resuscitation 1, 2.

• Target urine output >0.5 ml/kg body weight 1
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1
• Vigorous fluid resuscitation is crucial in preventing systemic complications, particularly in the first 48-72 hours 4, 5

Oxygenation and Respiratory Support

• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 1, 2
• Hypoxia and acidosis may be detected late by clinical means alone, requiring regular arterial blood gas analysis 1

Pain Management

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

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

Nutritional Management

Initiate oral feeding immediately in mild cases and advance regular diet as tolerated—do not keep patients NPO 1, 2.

• In severe cases requiring nutritional support, attempt enteral nutrition first via nasogastric tube (effective in 80% of cases) or nasoenteral tube if oral feeding not tolerated 1, 2
• Nasogastric route is as effective as nasojejunal route 2
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 1
• Enteral nutrition is associated with lower rates of complications including death, multiorgan failure, and systemic infections compared to parenteral nutrition 6

Antibiotic Strategy

Do not use prophylactic antibiotics in mild pancreatitis or biliary pancreatitis—there is no evidence of benefit 1, 2.

• Consider prophylactic antibiotics only in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 2, 4
• Limit antibiotic duration to maximum 14 days 1, 2
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost if antibiotics are used 1
• In severe cases with >30% necrosis, imipenem/cilastatin decreases risk of pancreatic infection 6

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 1, 2, 4.

• Perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days of admission for severe cases to identify pancreatic necrosis 1, 2
• CT imaging is required for patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 4

Management of Gallstone Pancreatitis

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

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 3, 1, 2
• Always perform ERCP under antibiotic cover 1
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 1
• If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 1
• After mild attack, perform cholecystectomy during same admission or within two weeks after discharge to prevent recurrent potentially fatal pancreatitis 3
• Delay cholecystectomy in severe cases until signs of lung injury and systemic disturbance have resolved 3

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 and clinical suspicion of sepsis 3, 1, 2.

• FNA accuracy is 89-100% for diagnosing infected necrosis 5
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 3, 1, 2
• Infected necrosis carries 40% mortality 2
• For sterile necrosis, continue non-surgical treatment 5
• Necrosectomy should be performed as late as possible when indicated 5
• Percutaneous wide bore drainage may be sufficient for pancreatic abscess with 31-50% primary success rate 3
• Thorough surgical debridement is essential if surgical intervention required 3

Critical Monitoring Parameters

• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature in severe cases 1
• Patients with organ failure persisting >48 hours during first week are at greatest risk of death 3
• Re-evaluate severity repeatedly as condition is unstable especially in early stage 5

Common Pitfalls to Avoid

• Do not routinely use antibiotics in mild pancreatitis 1, 2
• Do not delay ERCP in severe gallstone pancreatitis with cholangitis 1, 2
• Do not use aggressive fluid resuscitation instead of goal-directed moderate resuscitation 1, 2
• Do not keep patients NPO when they can tolerate oral feeding 1, 2
• Do not overuse CT scanning in mild cases with clinical improvement 1, 2, 4
• Do not delay definitive treatment of gallstones more than two weeks after discharge 3