What are the treatment and management options for a patient diagnosed with pancreatitis?

Pancreatitis Diagnosis, Treatment and Management

Immediate Diagnosis

Diagnose acute pancreatitis when two of three criteria are present: epigastric abdominal pain, elevated lipase, and imaging findings of pancreatic inflammation. 1

• Do not routinely order CT scanning in suspected mild cases—reserve contrast-enhanced CT or MRI for patients with unclear diagnosis or those failing to improve clinically 2
• Identify the underlying cause in at least 80% of cases to prevent recurrence, with gallstones and alcohol being the most common etiologies 3

Initial Severity Assessment (First 24-48 Hours)

All patients with suspected acute pancreatitis must be admitted to hospital for proper diagnosis and severity stratification—this cannot be adequately performed outpatient. 4

• Use APACHE II score, clinical impression of severity, or obesity assessment within the first 24 hours 5
• Measure C-reactive protein at 48 hours (>150 mg/L indicates severe disease) or calculate Glasgow score (≥3 indicates severity) 5
• Monitor vital signs closely including pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature 5
• Recognize that 80% of cases are mild and resolve with supportive care, but 20% can be severe requiring intensive monitoring 3

Immediate Management Based on Severity

Mild Acute Pancreatitis (80% of cases)

Start oral feeding immediately if the patient has no nausea or vomiting—early feeding is beneficial, not harmful. 3

• Low-fat, normal-fat, and solid foods have all been used successfully 3
• Control pain with NSAIDs with or without acetaminophen as first-line 4
• Moderate pain can be managed with weak opioids combined with non-opioid analgesics 4
• If opioids are prescribed, routinely prescribe laxatives to prevent constipation 4
• No antibiotic prophylaxis is indicated for mild disease 5
• No routine CT scanning is necessary unless clinical deterioration occurs 5

Severe Acute Pancreatitis (20% of cases)

All patients with severe acute pancreatitis, organ failure, or SIRS must be managed in an ICU or high dependency unit with full monitoring and organ support systems. 5, 3

• Establish peripheral and central venous access for fluid administration and CVP monitoring 5
• Provide aggressive intravenous fluid resuscitation, with Ringer's lactate preferred over normal saline 6, 7
• Early aggressive hydration is most beneficial within the first 12-24 hours and may have little benefit beyond 2
• Initiate enteral nutrition through a feeding tube if the patient cannot tolerate oral intake—this protects the gut barrier and reduces infection risk 3
• Avoid parenteral nutrition as it should not be used when enteral feeding is possible 2, 6
• Do not use routine prophylactic antibiotics in severe pancreatitis or sterile necrosis 5, 2

Management of Pancreatic Necrosis

In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, but all infected necrosis ultimately requires complete debridement of all cavities containing necrotic material. 5, 2

• Perform image-guided fine needle aspiration for culture in patients with persistent symptoms and >30% necrosis, or those with smaller necrosis but clinical suspicion of sepsis, at 7-14 days after onset 5
• In stable patients with infected necrosis, delay surgical, radiologic, or endoscopic drainage for preferably 4 weeks to allow wall formation around the necrosis 2
• Asymptomatic pancreatic or extrapancreatic necrosis and pseudocysts do not warrant intervention regardless of size, location, or extension 2

Gallstone Pancreatitis Management

Perform urgent therapeutic ERCP with sphincterotomy within 72 hours in patients with gallstone pancreatitis who have concurrent cholangitis, predicted or actual severe pancreatitis, jaundice, dilated common bile duct, or failure to improve within 48 hours despite intensive resuscitation. 5

• Patients with acute cholangitis require ERCP within 24 hours of admission 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 5
• All patients with gallstone pancreatitis must undergo cholecystectomy during the same hospital admission or within two weeks of discharge—never delay beyond two weeks as this dramatically increases recurrence risk. 4, 3

Discharge Criteria and Outpatient Management

Never discharge patients before severity assessment is complete at 48 hours, as organ failure can develop after initial presentation. 4

Patients with confirmed mild acute pancreatitis may be considered for early discharge only if they meet all of the following criteria: 4

• No organ failure
• Tolerating oral intake
• Pain adequately controlled
• No evidence of complications on imaging
• Etiology identified and addressed

Post-Discharge Management

• Manage mild pain with NSAIDs with or without acetaminophen 4
• Severe pain requiring stronger opioids warrants readmission for monitoring 4
• Schedule follow-up within 1-2 weeks to ensure complete resolution 4, 3
• Provide clear return precautions for worsening pain, fever, inability to tolerate oral intake, or jaundice 4
• For alcohol-induced pancreatitis, provide alcohol counseling to prevent recurrence 6

Prognosis

• Overall mortality for acute pancreatitis is less than 10% 3
• Mild pancreatitis has less than 5% mortality 3
• Severe pancreatitis has up to 30% mortality 3, 1