Initial Treatment of Acute Pancreatitis
All patients with acute pancreatitis require immediate vigorous fluid resuscitation with Lactated Ringer's solution using a moderate (not aggressive) approach, supplemental oxygen as needed, correction of electrolyte abnormalities, and adequate pain control. 1, 2
Fluid Resuscitation Strategy
Use Lactated Ringer's solution, not normal saline, as it significantly reduces systemic inflammation and SIRS at 24 hours. 2, 3 Multiple trials demonstrate LRS superiority over normal saline in reducing inflammatory markers. 4, 3
Employ moderate fluid resuscitation, not aggressive resuscitation. 5 The landmark 2022 WATERFALL trial definitively showed that aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) resulted in significantly higher fluid overload (20.5% vs 6.3%, P=0.004) without improving outcomes compared to moderate resuscitation. 5 This represents a critical paradigm shift from older guidelines.
Specific Fluid Protocol:
- Moderate resuscitation: 10 ml/kg bolus only if hypovolemic, then 1.5 ml/kg/hour maintenance 5
- Reassess at 12,24,48, and 72 hours and adjust based on clinical status 5
- Monitor for fluid overload, which occurs 2.85 times more frequently with aggressive approaches 5
Severity Assessment
Determine severity within 24-48 hours using: 1, 2
- APACHE II score >8 1
- Persistent organ failure beyond 48 hours (this defines severe pancreatitis) 2
- C-reactive protein >150 mg/L at 48 hours 1, 2
- Clinical impression and presence of obesity 2
Triage patients with predicted severe disease or persistent organ failure to ICU/intermediate care unit with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output. 1, 2
Early Nutrition
Start oral feeding within 24 hours if tolerated—do not keep patients NPO. 6, 7, 2 Early feeding reduces the need for interventions for necrosis by 2.5-fold and protects the gut mucosal barrier. 7
If oral intake is not tolerated, use nasojejunal tube feeding with elemental or semi-elemental formula, not total parenteral nutrition. 1 Enteral nutrition is effective in 80% of cases and prevents infectious complications. 2
Provide 35-40 kcal/kg/day with protein 1.2-1.5 g/kg/day. 6 Supplement with B-complex vitamins, which are critical in alcohol users. 6
Management Specific to Gallstone Pancreatitis
Immediate Diagnostic Workup:
At admission, obtain: 7
- Serum lipase (preferred over amylase) 7
- Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) 1, 7
- Triglycerides and calcium 1, 7
- Abdominal ultrasound immediately to identify gallstones and assess common bile duct 1, 7
ERCP Timing—Critical Decision Points:
Urgent ERCP within 24 hours if concomitant cholangitis is present (fever, jaundice, biliary obstruction). 1, 7 Delaying ERCP in cholangitis significantly increases morbidity and mortality. 7, 2
Early ERCP within 72 hours if high suspicion of persistent common bile duct stone: 1, 7
- Visible CBD stone on imaging
- Persistently dilated common bile duct
- Progressive jaundice or worsening liver function tests
Do not perform routine urgent ERCP in gallstone pancreatitis without cholangitis or high suspicion of persistent CBD stone, as it does not reduce mortality or organ failure. 7
All ERCP procedures must be performed under antibiotic cover. 7, 2
Definitive Surgical Management:
Perform laparoscopic cholecystectomy during the same hospital admission if possible, and otherwise no later than 2-4 weeks after discharge. 1, 7 This is non-negotiable for patients fit for surgery with gallbladder in situ. Delaying beyond 2-4 weeks significantly increases risk of recurrent biliary events including potentially fatal repeat pancreatitis. 7, 2
Antibiotic Strategy
Do not use prophylactic antibiotics routinely in either mild or severe pancreatitis without documented infection. 7, 2 High-quality trials show no reduction in infected pancreatic necrosis (OR 0.81) or mortality (OR 0.85) with prophylactic antibiotics. 7
Reserve antibiotics only for documented infections: pneumonia, UTI, cholangitis, or line-related sepsis. 7
If antibiotic prophylaxis is used in substantial necrosis (>30% of gland), restrict to maximum 14 days. 1, 2
Imaging for Necrosis Assessment
Perform contrast-enhanced CT after 72 hours in patients with: 1
- APACHE II score >8
- Evidence of organ failure during initial 72 hours
- Persistent organ failure, signs of sepsis, or worsening clinical status 2
Do not perform routine CT in mild pancreatitis improving clinically. 2
Use CT within 3-10 days to assess degree of pancreatic necrosis in severe disease. 1, 2
Management of Necrosis
Sterile necrosis does not usually require therapy—close monitoring is appropriate unless clinical status deteriorates. 1, 7, 2
Patients with infected necrosis require intervention for complete debridement of all cavities containing necrotic material. 7, 2
Critical Pitfalls to Avoid
- Never use aggressive fluid resuscitation (20 ml/kg bolus + 3 ml/kg/hour)—this causes fluid overload without benefit 5
- Never delay ERCP in cholangitis—this increases morbidity and mortality 7, 2
- Never delay cholecystectomy beyond 2-4 weeks in surgical candidates—this significantly increases recurrent biliary events 7, 2
- Never use normal saline instead of Lactated Ringer's—LRS reduces inflammation 2, 3
- Never keep patients NPO beyond 24 hours if they can tolerate oral intake 6, 7, 2