What is the management of pancreatitis?

Management of Acute Pancreatitis

Initial Severity Stratification and Triage

All 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. 1, 2

• Complete severity stratification within 48 hours using clinical impression, APACHE II score (in first 24 hours), C-reactive protein >150 mg/L, Glasgow score ≥3, or persistent organ failure (>48 hours) 1, 2, 3
• Mild acute pancreatitis (80% of cases) has <5% mortality and runs a self-limiting course; these patients can be managed on general wards with basic monitoring 1, 2, 3
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2, 3
• Infected necrosis with organ failure carries 35.2% mortality, while sterile necrosis with organ failure has 19.8% mortality 2, 3

Fluid Resuscitation

Use Lactated Ringer's solution rather than normal saline for initial fluid resuscitation. 4, 5, 6

• Target urine output >0.5 ml/kg body weight 2, 3
• Lactated Ringer's solution is superior to normal saline in reducing systemic inflammatory response syndrome (SIRS) at 24 hours 4
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 2, 3
• Use goal-directed moderate fluid resuscitation rather than aggressive fluid resuscitation, as aggressive resuscitation in predicted severe disease may be futile and deleterious 5, 6, 7

Monitoring Requirements

For Mild Pancreatitis:

• Monitor temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and urine output 1, 2, 3
• Peripheral intravenous line for fluids and possibly nasogastric tube 1

For Severe Pancreatitis:

• Peripheral venous access plus central venous line for fluid administration and CVP monitoring 1, 2
• Indwelling urinary catheter and nasogastric tube 1
• Regular hourly assessment of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1, 2
• Regular arterial blood gas analysis to detect hypoxia and acidosis, which may be detected late by clinical means alone 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess adequate tissue perfusion 2
• Strict asepsis in placement and care of invasive monitoring equipment as these may serve as sources of subsequent sepsis 1, 2

Pain Management

Prioritize aggressive pain control using dilaudid over morphine or fentanyl in non-intubated patients. 2

• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 2, 5
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 2
• Avoid NSAIDs in acute kidney injury 2

Nutritional Support

Initiate early enteral nutrition rather than total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2, 3

• Early oral feeding within 24 hours is recommended in mild cases as tolerated 2, 3, 7
• Both gastric (nasogastric) and jejunal feeding can be delivered safely; nasogastric route is effective in 80% of cases 1, 2
• Early enteral nutrition should be initiated even in severe cases 2
• TPN should be avoided, but partial parenteral nutrition integration can be considered if enteral route is not completely tolerated 2
• If ileus persists for more than five days, parenteral nutrition will be required 2

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis, as there is no evidence they improve outcomes or reduce septic complications. 1, 2, 3

• In severe acute pancreatitis with evidence of pancreatic necrosis, the evidence for prophylactic antibiotics is conflicting and difficult to interpret; some trials show benefit, others do not, and there is no consensus 1
• If antibiotic prophylaxis is used in severe cases, intravenous cefuroxime is a reasonable balance between efficacy and cost, given for a maximum of 14 days 1, 2
• Antibiotics are warranted when specific infections occur (chest, urine, bile, or cannula related) 1, 2
• Consider procalcitonin-based algorithms to distinguish between inflammation and infection and limit unwarranted antibiotic use 5, 7

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 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 1, 2
• Patients with signs of cholangitis (fever, rigors, positive blood cultures) require immediate therapeutic ERCP with endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 1, 2
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 2
• ERCP should always be performed under antibiotic cover 2
• All patients with biliary pancreatitis should undergo definitive management of gallstones (laparoscopic or open cholecystectomy with operative cholangiography) during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks 1, 2, 7

Imaging Strategy

Obtain dynamic CT scanning with non-ionic contrast within three to 10 days of admission in severe cases to identify pancreatic necrosis and guide management. 2, 3

• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 2, 3
• Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6–10 days after admission will require computed tomography 1
• Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement in severe cases 2
• Patients with mild pancreatitis require further CT only if there is a change in clinical status suggesting a new complication 2

Management of Pancreatic Necrosis and Infected Necrosis

Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material. 1, 2

• 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 1
• Consider minimally invasive approaches (including lumen-apposing metal stent for transgastric drainage) for debridement of infected necrosis before open surgical necrosectomy 2, 3, 5
• Delay drainage as much as possible since it is associated with fewer procedures 5
• Infected necrosis is the most serious local complication with a high mortality rate (40%) 2
• Many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear 5

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. 1, 2, 3

• 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 intensive therapy unit care, or interventional radiological, endoscopic, or surgical procedures 1, 2
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 2, 3
• Each case should be managed in an individualized way by a multidisciplinary specialist pancreatic team 2

Etiological Investigation

• The etiology of acute pancreatitis should be determined in 75–80% of cases, and no more than 20–25% should be classified as "idiopathic" 1, 3
• Obtain serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, and transabdominal ultrasound 8
• Early ultrasound for gallstones should be repeated if initially negative 3

Pharmacological Treatment

• No specific pharmacological treatment except for organ support and nutrition has proven effective 2
• Despite extensive research, antiproteases (gabexate), antisecretory agents (octreotide, somatostatin), anti-inflammatory agents, fresh frozen plasma, and peritoneal lavage have not shown benefit and cannot be recommended 1, 2

Common Pitfalls to Avoid

• Delaying drainage of infected collections leads to sepsis and increased mortality 2, 3
• Using prophylactic antibiotics routinely in mild cases provides no benefit 1, 2, 3
• Aggressive fluid resuscitation in patients with predicted severe disease might be futile and deleterious 5, 6
• Using normal saline instead of Lactated Ringer's solution for initial resuscitation 4, 5, 6, 7