What are the management strategies for acute pancreatitis?

Management of Acute Pancreatitis

Initial Severity Stratification and Triage

All patients with acute pancreatitis require severity stratification within 48 hours of presentation to guide appropriate level of care and monitoring intensity. 1, 2

• Mild acute pancreatitis (80% of cases) has <5% mortality and typically follows a self-limiting course 1, 2
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 1, 2
• Patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high dependency unit (HDU) with full monitoring and systems support 3, 1

Fluid Resuscitation Strategy

Moderate fluid resuscitation with lactated Ringer's solution is recommended over aggressive fluid resuscitation, as aggressive protocols increase fluid overload without improving clinical outcomes. 4

Fluid Type and Volume

• Lactated Ringer's solution is superior to normal saline, reducing systemic inflammatory response syndrome (SIRS) at 24 hours and C-reactive protein levels 5, 6
• Moderate resuscitation protocol: 10 ml/kg bolus only if hypovolemic (no bolus if normovolemic), followed by 1.5 ml/kg per hour 4
• Avoid aggressive resuscitation (20 ml/kg bolus followed by 3 ml/kg per hour) as it increases fluid overload risk 2.85-fold without benefit 4
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2

Resuscitation Goals

• Target urine output >0.5 ml/kg body weight 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1

The 2022 WATERFALL trial fundamentally changed practice by demonstrating that aggressive fluid resuscitation causes harm (20.5% fluid overload vs 6.3% with moderate resuscitation) without reducing moderately severe or severe pancreatitis rates. 4 This directly contradicts older guidelines recommending aggressive hydration.

Monitoring Requirements

Mild Acute Pancreatitis

• Manage on general ward with basic monitoring 3
• Regular assessment of temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and urine output 1, 2
• Peripheral intravenous line for fluids 3
• Nasogastric tube if needed 3

Severe Acute Pancreatitis

• Require ICU or HDU admission with intensive monitoring 3, 1
• Peripheral venous access plus central venous line for fluid administration and CVP monitoring 1, 7
• Indwelling urinary catheter 1, 7
• Nasogastric tube 1, 7
• Regular hourly vital signs: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature 1
• Regular arterial blood gas analysis to detect hypoxia and acidosis early 7
• Swan-Ganz catheter if cardiocirculatory compromise exists or initial resuscitation fails 3

Pain Management

Pain control is a clinical priority requiring aggressive management without restrictions on medication. 1, 2

• Dilaudid is preferred over morphine or fentanyl in non-intubated patients 1
• Avoid NSAIDs in acute kidney injury 1
• Epidural analgesia should be considered as an alternative or adjunct to intravenous analgesia in a multimodal approach 1, 2
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1

Nutritional Support

Enteral nutrition is strongly preferred over total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2

• Early enteral nutrition should be initiated, even in severe cases 1
• Both gastric (nasogastric) and jejunal feeding routes are safe and effective 1
• Nasogastric route is effective in 80% of cases 3
• Early oral feeding within 24 hours is recommended in mild cases as tolerated 2
• TPN should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 1
• If ileus persists for more than five days, parenteral nutrition will be required 1

Antibiotic Therapy

Prophylactic antibiotics should NOT be administered routinely in mild acute pancreatitis as there is no evidence they improve outcomes or reduce septic complications. 3, 1, 2

• Antibiotics are warranted only when specific infections occur (chest, urine, bile, or cannula-related) 3, 1
• In severe acute pancreatitis with pancreatic necrosis, evidence for prophylactic antibiotics is conflicting with no current consensus 3, 2
• If antibiotic prophylaxis is used in severe cases, it should be given for a maximum of 14 days 3
• Intravenous cefuroxime is a reasonable balance between efficacy and cost for prophylaxis in severe cases if chosen 1

This represents a major pitfall: using prophylactic antibiotics routinely in mild cases provides no benefit and should be avoided. 2

Management of Biliary Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 3, 1, 2

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 3, 1
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 3
• All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks 3

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration. 3, 1, 2

• Dynamic CT scanning should be obtained in severe cases to identify pancreatic necrosis and guide management 1, 2
• Patients with persistent organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require computed tomography 3
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 1

Management of Pancreatic Necrosis and Complications

All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration. 3

• Infected necrosis is the most serious local complication with 40% mortality 1
• Infected necrosis with organ failure carries 35.2% mortality, sterile necrosis with organ failure 19.8% mortality 2
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 3, 2
• Minimally invasive approaches for debridement should be considered before open surgical necrosectomy 1, 2
• The choice of surgical technique depends on individual features and locally available expertise 3

Delaying drainage of infected collections leads to sepsis and increased mortality—this is a critical pitfall to avoid. 2

Specific Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective. 1, 2

• Aprotinin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have no proven value and cannot be recommended 3, 1
• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1

Specialist Care and Multidisciplinary Approach

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 3, 1, 2

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications who may require ICU care, or interventional radiological, endoscopic, or surgical procedures 3, 1
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team 1

Etiological Investigation

The etiology of acute pancreatitis should be determined in at least 80% of cases, with no more than 20% classified as "idiopathic". 3, 2

• Early ultrasound for gallstones should be performed 2
• Bile sampling for assessment of microlithiasis may be required in patients with repeated attacks where no other cause has been found 3
• Endoscopic ultrasound may be used to select which patients should undergo diagnostic or therapeutic ERCP 3

Audit Standards

• Overall mortality should be lower than 10%, and less than 30% in severe pancreatitis 3
• Correct diagnosis should be made in all patients within 48 hours of admission 3
• Severity stratification should be made in all patients within 48 hours of diagnosis 3