What is the treatment approach for a patient with acute pancreatitis?

Treatment of Acute Pancreatitis

Initiate moderate fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr following a 10 ml/kg bolus only if hypovolemic, while avoiding aggressive fluid protocols that increase mortality and fluid overload complications. 1, 2

Initial Assessment and Triage

Severity stratification must occur within 48 hours to determine the intensity of monitoring and intervention required 3, 1:

• Mild pancreatitis (80% of cases): Mortality <5%, can be managed on general ward with basic vital sign monitoring 1, 4
• Severe pancreatitis (20% of cases): Mortality 15-35%, requires ICU or high dependency unit admission with full hemodynamic monitoring and systems support 5, 3

Use APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure >48 hours to stratify severity 1

Fluid Resuscitation Strategy

The 2022 WATERFALL trial fundamentally changed fluid management by demonstrating that aggressive resuscitation increases fluid overload (20.5% vs 6.3%) without improving outcomes 2. This represents the highest quality recent evidence and should guide practice.

Specific fluid protocol 1, 4:

• Initial bolus: 10 ml/kg in hypovolemic patients OR no bolus in normovolemic patients
• Maintenance rate: 1.5 ml/kg/hr for first 24-48 hours
• Total limit: <4000 ml in first 24 hours
• Fluid type: Lactated Ringer's solution (superior to normal saline in reducing SIRS and organ failure) 1

Monitoring targets during resuscitation 3, 4:

• Urine output >0.5 ml/kg/hr
• Heart rate, blood pressure normalization
• Hematocrit, blood urea nitrogen, creatinine, lactate as markers of tissue perfusion
• Central venous pressure in severe cases

Critical pitfall: Avoid aggressive fluid rates (>10 ml/kg/hr or >250-500 ml/hr) as these increase complications and mortality without benefit 1, 4

Pain Management

Use hydromorphone (Dilaudid) as first-line analgesic in non-intubated patients, preferred over morphine or fentanyl 3, 1

Multimodal approach 3, 1:

• Patient-controlled analgesia (PCA) should be integrated with every strategy
• Epidural analgesia as alternative or adjunct for moderate to severe pain
• Avoid NSAIDs if any evidence of acute kidney injury

Nutritional Support

Early enteral nutrition is strongly preferred over parenteral nutrition to prevent gut failure and infectious complications 3, 1

Feeding protocol based on severity 3, 1:

• Mild pancreatitis: Regular oral diet within 24 hours if no nausea/vomiting
• Moderately severe/severe pancreatitis: Enteral nutrition via nasogastric or nasojejunal route
• Both gastric and jejunal feeding routes are safe and effective 3
• TPN should be avoided; partial parenteral nutrition only if enteral route not tolerated 3
• If ileus persists >5 days, parenteral nutrition becomes necessary 3

Antibiotic Therapy

Prophylactic antibiotics are NOT recommended in acute pancreatitis, as they do not reduce mortality or morbidity 3, 1, 6

Indications for antibiotics 3, 1:

• Documented infected necrosis (confirmed by CT-guided fine needle aspiration)
• Specific documented infections (respiratory, urinary, biliary, catheter-related)
• High risk for intra-abdominal candidiasis

If prophylaxis used in severe necrosis (controversial, no consensus) 5:

• Maximum duration 14 days
• Intravenous cefuroxime provides reasonable balance between efficacy and cost 3

Management of Biliary Pancreatitis

Urgent therapeutic ERCP is indicated within 72 hours in patients with 5, 3, 1:

• Severe acute pancreatitis of gallstone etiology
• Cholangitis (requires immediate sphincterotomy or stenting)
• Jaundice
• Dilated common bile duct

All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 5, 3

ERCP is NOT routinely indicated in uncomplicated gallstone pancreatitis 1

Cholecystectomy timing 5:

• Should occur during same hospital admission or within 2 weeks of discharge to prevent recurrent pancreatitis
• Delay in severe pancreatitis until lung injury and systemic disturbance resolve

Imaging Strategy

CT scanning approach 3, 1:

• Mild cases: Routine CT unnecessary unless clinical deterioration or diagnostic uncertainty
• Severe cases: Dynamic contrast-enhanced CT to identify pancreatic necrosis and guide management
• Timing: Patients with persistent organ failure, sepsis signs, or deterioration at 6-10 days require CT 5
• Follow-up imaging: Only if clinical status deteriorates or fails to improve

Initial imaging should include transabdominal ultrasound for gallstones 1

Management of Pancreatic Necrosis

All patients with >30% pancreatic necrosis and persistent symptoms, or smaller necrosis with clinical suspicion of sepsis, should undergo CT-guided fine needle aspiration at 7-14 days to obtain material for culture 5

Infected necrosis management 5, 3, 1:

• Requires intervention to completely debride all cavities containing necrotic material
• Delay intervention preferably for 4 weeks in stable patients to allow wall formation 6
• Minimally invasive approaches (percutaneous drainage, retroperitoneal or laparoscopic necrosectomy) should be considered before open surgical necrosectomy 3, 1
• Mortality rate 35-40% with infected necrosis 3, 1

Sterile necrosis: Managed conservatively, no intervention required regardless of size 6

Monitoring Requirements

Severe pancreatitis monitoring in ICU/HDU 3, 4:

• Continuous vital signs: pulse, blood pressure, respiratory rate, oxygen saturation, temperature
• Hourly urine output
• Central venous pressure monitoring
• Peripheral venous access, central venous line, urinary catheter, nasogastric tube 3

Oxygen therapy: Maintain arterial oxygen saturation >95% 4

Specialist Care Requirements

Every hospital receiving acute admissions should have a single nominated clinical team to manage all acute pancreatitis patients 5, 3

Referral to specialist unit necessary for 5, 3:

• Extensive necrotizing pancreatitis (>30% necrosis)
• Complications requiring ICU care
• Need for interventional radiological, endoscopic, or surgical procedures
• Multidisciplinary team approach essential 3, 1

Treatments Without Proven Benefit

Do not use 1, 4:

• Aprotinin, glucagon, somatostatin, octreotide
• Fresh frozen plasma
• Peritoneal lavage
• Prophylactic antibiotics in mild or sterile pancreatitis