What is the best approach to manage a patient with acute pancreatitis?

Management of Acute Pancreatitis

Initial Assessment and Triage

All patients with severe acute pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support. 1, 2 This is non-negotiable for patients with persistent organ failure, extensive necrosis (>30%), or signs of sepsis.

• Every hospital receiving acute admissions should designate a single clinical team to manage all acute pancreatitis cases 3, 1
• Severity stratification must be completed within 48 hours of diagnosis 3
• Patients with mild pancreatitis can be managed on general wards with close monitoring 1

Immediate Resuscitation and Monitoring

Aggressive fluid resuscitation with Lactated Ringer's solution is the cornerstone of early management, targeting urine output >0.5 ml/kg/hour. 1, 4

• Establish peripheral venous access; place central venous line in severe cases for CVP monitoring 1
• Monitor vital signs hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature 1, 2
• Insert urinary catheter and nasogastric tube in severe cases 1
• Track hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1, 2

Common pitfall: Avoid overly aggressive fluid protocols, as excessive resuscitation increases mortality and complications without improving outcomes 2

Pain Management

Use a multimodal approach with Dilaudid as the preferred opioid in non-intubated patients. 1

• Avoid NSAIDs in patients with acute kidney injury 1, 2
• Consider epidural analgesia as adjunct for patients requiring high-dose opioids for extended periods 1, 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1
• Adequate analgesia is safe and does not worsen pancreatitis 4

Nutritional Support

Initiate early enteral nutrition within 24 hours via nasogastric or nasojejunal tube—both routes are equally safe. 1, 2

• Enteral nutrition prevents gut failure and infectious complications compared to total parenteral nutrition 1, 2
• Start feeding even in severe cases unless there is severe ileus, nausea, or vomiting 2
• If ileus persists beyond 5 days, initiate parenteral nutrition 1
• Partial parenteral nutrition can supplement enteral feeding if the enteral route is not fully tolerated 1

For patients with intra-abdominal pressure (IAP) >15 mmHg: Start nasojejunal feeding at 20 mL/hour with rate increases based on tolerance 2

For patients with IAP >20 mmHg or abdominal compartment syndrome: Discontinue enteral nutrition and initiate parenteral nutrition 2

Antibiotic Therapy

Do not give prophylactic antibiotics in mild acute pancreatitis. 1, 2

In severe acute pancreatitis with pancreatic necrosis, prophylactic antibiotics may reduce complications and mortality. 1

• Use intravenous cefuroxime as a reasonable balance between efficacy and cost 1
• Limit prophylactic antibiotics to maximum 14 days in the absence of positive cultures 3, 2
• Administer antibiotics only when specific infections are documented (chest, urine, bile, cannula-related, or infected necrosis) 1, 2

Critical point: Prophylactic antibiotics do not prevent infection of pancreatic necrosis according to recent evidence, so reserve them for documented infections 2

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 1

• Obtain dynamic contrast-enhanced CT within 3-10 days in severe cases to identify pancreatic necrosis 2
• Use CT with dedicated pancreas protocol for patients with persistent organ failure, sepsis signs, or clinical deterioration 6-10 days after admission 3
• Follow-up CT is indicated only if clinical status deteriorates or fails to improve 1

Management of Biliary Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with gallstone pancreatitis who have cholangitis, jaundice, or dilated common bile duct. 1, 2

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy regardless of whether stones are found 1
• Perform definitive management of gallstones (cholecystectomy) during the same hospital admission, or within 2-4 weeks if not possible during admission 3, 2
• Ultrasound examination of the gallbladder should be available within 24 hours of diagnosis 3

Management of Pancreatic Necrosis

For patients with persistent symptoms and >30% pancreatic necrosis, perform image-guided fine needle aspiration to detect infection. 3, 2

Sterile necrosis: Manage conservatively with fluid resuscitation, nutritional support, and monitoring—no intervention required 2

Infected necrosis (mortality 40%): 1

• Delay intervention until at least 4 weeks after disease onset when possible, as this reduces mortality 2
• Implement a step-up approach: start with percutaneous or endoscopic drainage, progress to minimally invasive necrosectomy only if no improvement 2
• Complete debridement of all cavities containing necrotic material is required 3, 2

Indications for early intervention (<4 weeks): 2

• Abdominal compartment syndrome unresponsive to conservative management
• Acute ongoing bleeding when endovascular approach fails
• Bowel ischemia or acute necrotizing cholecystitis

Indications for late intervention (>4 weeks): 2

• Infected necrosis with clinical deterioration

Specialist Referral Criteria

Refer to a specialist pancreatic unit for patients with extensive necrotizing pancreatitis (>30% necrosis) or complications requiring ICU care, interventional radiology, endoscopy, or surgery. 3, 1, 2

• Specialist units should have 24-hour access to contrast-enhanced CT/MRI, percutaneous drainage, angiography, and ERCP 3
• A multidisciplinary team approach is essential for optimal management 1

Audit Standards and Outcomes

• Overall mortality should be <10%; mortality in severe pancreatitis should be <30% 3
• Correct diagnosis should be made within 48 hours in all patients 3
• Determine etiology in at least 80% of cases 3

Common pitfall: The mortality from necrotizing pancreatitis is 30-40%, with one-third of deaths occurring early from organ failure and most later deaths from infected necrosis 2

What Does NOT Work

No specific pharmacological treatment has proven effective beyond supportive care. 1

• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents have not shown benefit 1