What is the treatment for pancreatitis?

Treatment of Acute Pancreatitis

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support, while mild cases can be managed on a general medical ward with goal-directed moderate fluid resuscitation using Lactated Ringer's solution, immediate oral feeding when tolerated, and avoidance of routine prophylactic antibiotics. 1, 2

Initial Severity Assessment and Triage

Severity classification determines the entire treatment approach and must be performed immediately upon diagnosis. 1, 3

• Use clinical impression of severity, obesity, APACHE II score in the first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours to predict severity 4, 1
• Severe disease represents only 20% of cases but accounts for 95% of mortality, while mild disease comprises 80% of cases with <5% mortality 2, 3
• Organ failure that resolves within 48 hours should not be classified as severe pancreatitis 4

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, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1, 2
• A critical pitfall is aggressive fluid resuscitation, which should be avoided in favor of moderate, goal-directed therapy 1, 3

Nutritional Management

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

• Advance regular diet as tolerated with appropriate pain management 1, 2
• If oral feeding is not tolerated, use enteral nutrition via nasogastric tube, which is effective in 80% of cases 4, 1
• Enteral nutrition is preferred over parenteral nutrition when nutritional support is required 4, 3
• Keeping patients NPO when they can tolerate oral feeding is a common pitfall that should be avoided 1

Pain Management

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

• Consider epidural analgesia as an alternative or adjunct in a multimodal approach for severe cases 1, 2

Antibiotic Strategy

Do not use prophylactic antibiotics routinely in mild acute pancreatitis or biliary pancreatitis. 1, 2

• Prophylactic antibiotics may be considered only in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 2, 3
• If antibiotics are used, limit duration to a maximum of 14 days 4, 3
• Intravenous cefuroxime provides a reasonable balance between efficacy and cost if antibiotics are indicated 1
• The evidence on antibiotic prophylaxis remains conflicting with no clear consensus, but the trend is toward more restricted use 4, 3

Imaging Strategy

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

• Obtain CT for patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 4, 3
• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs—overuse of CT in improving mild cases is a common pitfall 1, 3
• Ultrasonography is often unhelpful for pancreatic imaging 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. 4, 1, 2

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 4, 1
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 4
• 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, 2
• Delaying ERCP in severe gallstone pancreatitis with cholangitis is a critical pitfall that can worsen outcomes 1, 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 of necrosis and clinical suspicion of sepsis. 1, 2, 3

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 4, 1, 2
• Infected necrosis carries 40% mortality 1
• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 4, 2

Monitoring Requirements for Mild Pancreatitis

• Monitor vital signs on a general ward with peripheral venous access for fluid administration 1
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep arterial saturation >95% 1, 3

Referral Criteria

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis, complications requiring ICU care, or need for interventional radiological, endoscopic, or surgical procedures. 1

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