What is the treatment approach for pancreatitis?

Treatment of Acute Pancreatitis

Severity-Based Treatment Algorithm

The cornerstone of pancreatitis management is immediate severity classification—mild disease (80% of cases) requires only supportive ward care, while severe disease (20% of cases, 95% of deaths) demands ICU-level monitoring and aggressive intervention. 1, 2

Mild Acute Pancreatitis (80% of cases)

Setting and Monitoring:

• Manage on general medical ward with basic vital sign monitoring 1, 3
• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 3, 2
• Routine CT scanning is unnecessary unless clinical deterioration occurs 1, 3, 2

Fluid Resuscitation:

• Use Lactated Ringer's solution for goal-directed moderate fluid resuscitation—not aggressive resuscitation 2, 4
• 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

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 3, 2

Pain Control:

• Use Dilaudid as 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, 4

Antibiotic Use:

• Do not use prophylactic antibiotics in mild pancreatitis—there is no evidence of benefit 1, 3, 2

Severe Acute Pancreatitis (20% of cases)

Setting and Monitoring:

• Manage in high dependency unit or intensive care unit with full monitoring and systems support 1, 3, 2
• Establish peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 1, 2
• Monitor hourly: pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature 1, 2
• Perform regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 2

Fluid Resuscitation:

• Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution 2, 4
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1, 2

Nutritional Support:

• Attempt enteral nutrition first via nasogastric or nasoenteral tube if oral feeding not tolerated 1, 2
• Nasogastric feeding is effective in 80% of cases and is as safe as jejunal feeding 1, 3
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 2

Antibiotic Prophylaxis:

• Use prophylactic antibiotics in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 2
• Limit duration to maximum 14 days 3, 2
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 2
• Evidence on antibiotic prophylaxis remains conflicting, but may reduce complications and deaths in necrotizing disease 1, 3

Imaging:

• Perform dynamic contrast-enhanced CT within 3-10 days of admission to identify pancreatic necrosis 1, 2
• Obtain imaging in patients with persisting organ failure, signs of sepsis, or deterioration 6-10 days after admission 3

Etiology-Specific Management: Gallstone Pancreatitis

ERCP Indications:

• Do not perform ERCP in the absence of cholangitis—this is a critical recommendation 1
• Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis accompanied by cholangitis, jaundice, or dilated common bile duct 1, 3, 2
• Always perform ERCP under antibiotic cover 2
• If patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 2

Cholecystectomy:

• Perform cholecystectomy during the initial admission unless a clear plan exists for treatment within two weeks 1, 3

Management of Pancreatic Necrosis

Diagnosis:

• 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, 2
• Fine needle aspiration accuracy is 89-100% 5

Treatment:

• Patients with sterile necrosis should receive non-surgical treatment 5
• Infected necrosis carries 40% mortality and requires complete debridement of all cavities containing necrotic material 1, 3
• Delay drainage as much as possible since it is associated with fewer procedures 4
• Many patients with infected necrotizing pancreatitis can be treated with antibiotics alone, although optimal choice and duration remain unclear 4
• When intervention is required, options include percutaneous drainage, endoscopic approaches (including lumen-apposing metal stents for transgastric drainage), laparoscopic, or surgical necrosectomy 5, 4
• Necrosectomy should be performed as late as possible 5

Common Pitfalls to Avoid

• Routine use of antibiotics in mild pancreatitis 3
• Delaying ERCP in severe gallstone pancreatitis with cholangitis 3
• Failing to provide adequate nutritional support 3
• Overuse of CT scanning in mild cases with clinical improvement 3
• Keeping patients NPO when they can tolerate oral feeding 1
• Aggressive fluid resuscitation instead of goal-directed moderate resuscitation 1, 4

Multidisciplinary Care Requirements

• Every hospital receiving acute admissions should have a single nominated clinical team to manage all pancreatitis patients 1
• Management in or referral to a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or other complications 1