What is the best approach for managing a patient with acute pancreatitis, particularly one with a history of gallstones?

Management of Acute Pancreatitis

All patients with acute pancreatitis require immediate aggressive fluid resuscitation, severity assessment within 24-48 hours, and—if gallstones are present—same-admission cholecystectomy (ideally within 2 weeks, no later than 4 weeks) to prevent potentially fatal recurrent pancreatitis. 1, 2, 3

Initial Assessment and Diagnosis

Obtain serum lipase (preferred over amylase), liver function tests, triglycerides, and calcium at admission, along with immediate abdominal ultrasonography to identify gallstones and assess for common bile duct dilation. 1, 3

• Early elevation of serum aminotransferases or bilirubin strongly suggests gallstone etiology 1, 3
• Diagnosis should be established within 48 hours of admission 4
• Reserve contrast-enhanced CT or MRI for patients with unclear diagnosis or failure to improve clinically 5

Severity Stratification

Assess severity within the first 24-48 hours using clinical impression, APACHE II score, obesity, or C-reactive protein >150 mg/L at 48 hours, as this determines urgency and intensity of intervention. 1, 2, 3

• Severe pancreatitis is defined by persistent organ failure beyond 48 hours 1
• Patients with persisting organ failure or systemic inflammatory response syndrome require ICU or HDU admission 2, 5
• Repeat severity assessment at least within 48 hours, as mild disease can progress to severe 6

Immediate Supportive Care

Initiate aggressive goal-directed intravenous fluid resuscitation immediately upon presentation, as this is most beneficial within the first 12-24 hours. 3, 5

• Provide supplemental oxygen as needed, correct electrolyte and metabolic abnormalities, and ensure adequate pain control 1, 3
• All severe cases must be managed in HDU or ICU with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output 4, 1, 2, 3

Imaging for Complications

Obtain dynamic CT with non-ionic contrast within 3-10 days of admission (not initially) in patients with severe pancreatitis, persistent organ failure, signs of sepsis, or clinical deterioration to assess for pancreatic necrosis and peripancreatic fluid collections. 4, 1, 2

Management of Gallstone Pancreatitis: ERCP Indications

Perform urgent therapeutic ERCP with sphincterotomy IMMEDIATELY in patients with concomitant cholangitis, as delay increases morbidity and mortality. 1, 2, 3

• All ERCPs must be performed under antibiotic cover 1
• Additional indications for urgent ERCP within 72 hours include: jaundice with suspected/proven gallstone etiology, dilated common bile duct, or failure to improve within 48 hours despite intensive resuscitation 1, 2, 3
• Endoscopic sphincterotomy or duct drainage by stenting is required to ensure relief of biliary obstruction 4, 1
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 4

Definitive Management: Cholecystectomy Timing

All patients with gallbladder in situ MUST undergo laparoscopic cholecystectomy during the same hospital admission as soon as clinically recovered, ideally within 2 weeks and absolutely no later than 4 weeks after discharge. 1, 2, 3

• Delaying cholecystectomy beyond 2-4 weeks increases recurrent biliary events by 56%, including potentially fatal repeat pancreatitis 1, 2, 3
• Preoperative assessment should include liver biochemistry and ultrasound examination of the common bile duct 1, 2
• For patients unfit for surgery due to high surgical risk, ERCP with sphincterotomy alone is adequate definitive treatment to prevent recurrence 2, 3

Nutritional Support

If nutritional support is required, use the enteral route (nasogastric or nasojejunal) rather than total parenteral nutrition, as enteral feeding protects the gut mucosal barrier and reduces bacterial translocation. 4, 3, 5

• Nasogastric feeding is effective in 80% of cases 4, 3
• In mild pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting 5

Antibiotic Use

Routine prophylactic antibiotics in patients with severe acute pancreatitis and/or sterile necrosis are NOT recommended. 5

• The evidence for antibiotic prophylaxis is conflicting and there is no consensus 4
• If antibiotic prophylaxis is used, limit to a maximum of 14 days 4, 3
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost 3
• In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention 5

Management of Necrosis

Sterile necrosis does not require intervention and can be closely monitored unless the patient's clinical status deteriorates. 1, 7

• All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 4
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 4, 1, 2
• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for 4 weeks to allow wall formation around the necrosis 2, 5

Referral and Specialist Care

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or complications requiring ICU care, or interventional radiological, endoscopic, or surgical procedures. 4

Critical Pitfalls to Avoid

• Never delay ERCP in patients with cholangitis—this leads to increased morbidity and mortality 1, 2
• Never delay cholecystectomy beyond 2-4 weeks in patients fit for surgery—this significantly increases recurrent biliary events including potentially fatal repeat pancreatitis 1, 2, 3
• Never use parenteral nutrition when enteral feeding is tolerated 3, 5