What is the best course of treatment for a patient with hemorrhagic pancreatitis?

Treatment of Hemorrhagic Pancreatitis

All patients with hemorrhagic pancreatitis require immediate aggressive fluid resuscitation, intensive monitoring in an HDU or ICU setting, and should be managed by a specialized team with expertise in severe acute pancreatitis. 1, 2

Initial Resuscitation and Stabilization

Aggressive fluid resuscitation is the cornerstone of management and must be initiated immediately upon diagnosis. 3, 1

• Administer intravenous crystalloid solutions (isotonic crystalloids preferred) to maintain urine output >0.5 ml/kg body weight 3, 1
• Monitor central venous pressure frequently to guide fluid replacement rate in appropriate patients 3
• Maintain oxygen saturation >95% with supplemental oxygen 3
• Continuous monitoring of vital signs including pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature is essential 2
• Serial monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of tissue perfusion 2

A critical pitfall is inadequate initial fluid resuscitation, which was associated with shock, renal failure, and respiratory failure in historical series. 4 Early elevated hematocrit, BUN, or creatinine should prompt more intensive resuscitation measures. 5

Pain Management

• Use a multimodal approach to analgesia 1, 2
• Hydromorphone is preferred over morphine in non-intubated patients for severe pain 1
• Epidural analgesia may be considered for patients requiring high doses of opioids for extended periods 2
• Routinely prescribe laxatives to prevent opioid-induced constipation 1
• Avoid NSAIDs in patients with acute kidney injury 2

Intensive Care Unit Management

All patients with hemorrhagic pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 3, 2

• Hourly assessment of vital signs, respiratory status, and urine output 2
• Patients with persistent organ dysfunction despite adequate fluid resuscitation require ICU admission 2
• The translocation of large volumes of albumin-rich fluid from the intravascular compartment to the retroperitoneum and body cavities causes hemoconcentration, hypotension, tachycardia, respiratory insufficiency, and renal failure 4

Diagnostic Imaging

Contrast-enhanced CT should be obtained within 3-10 days of admission to assess for pancreatic necrosis. 2

• Use non-ionic contrast (100 ml bolus at 3 ml/s) with thin collimation (≤5 mm) through the pancreatic bed 3
• Images should be obtained approximately 40 seconds after injection start 3
• Non-opacification of at least one-third of the pancreas or an area >3 cm diameter indicates necrosis 3
• A second series at 65 seconds (portal venous phase) provides information about peripancreatic vein patency 3

Nutritional Support

Early enteral nutrition should be initiated when tolerated, preferably within 24 hours if the patient has no nausea, vomiting, or severe ileus. 1, 2

• Nasogastric feeding can be used safely and is effective in approximately 80% of cases 3, 6
• Nasojejunal tube is the preferred route if gastric feeding is not tolerated 2
• Enteral nutrition is strongly preferred over total parenteral nutrition to prevent gut failure and infectious complications 2
• Parenteral nutrition should be reserved only for patients who cannot tolerate enteral nutrition 2

Antibiotic Management

Prophylactic antibiotics are NOT routinely recommended and do not decrease mortality or morbidity. 1, 2

• The evidence for antibiotic prophylaxis is conflicting and difficult to interpret, with some trials showing benefit and others not 3
• If antibiotic prophylaxis is used, it should be given for a maximum of 14 days 3, 2
• Antibiotics should only be administered when specific infections are documented (infected necrosis, respiratory infections, urinary infections) 2
• Procalcitonin is the most sensitive test for detecting pancreatic infection 1

However, antibiotics ARE indicated in patients with biliary tract disease and penetrating ulcer where the risk of secondary infection is considerable. 4

Management of Pancreatic Necrosis

Patients with persistent symptoms and greater than 30% pancreatic necrosis should undergo image-guided fine needle aspiration to detect infection. 3, 2

• Fine needle aspiration has an accuracy of 89-100% for diagnosing infected necrosis 7
• Infected necrosis typically develops after 7-10 days of illness in patients with preexisting sterile necrosis 2
• Sterile necrosis should be managed conservatively with continued fluid resuscitation, nutritional support, and monitoring 2

For infected necrosis, interventions should be delayed until at least 4 weeks after disease onset when possible, as this results in lower mortality. 2

• Implement a step-up approach: start with percutaneous or endoscopic drainage, progressing to minimally invasive necrosectomy if no improvement occurs 2
• All patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 3, 2
• Resection of necrotic pancreas should be considered when the patient fails to improve after lavage and nonoperative resuscitation 4

Indications for Early Surgical Intervention

Early intervention (before 4 weeks) is indicated only for: 2

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

Management of Biliary Pancreatitis

If hemorrhagic pancreatitis is due to gallstones with concomitant cholangitis, jaundice, or dilated common bile duct, urgent ERCP should be performed within 24-72 hours. 3, 2

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 3
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting 3
• All patients with biliary pancreatitis should undergo definitive management of gallstones (cholecystectomy) during the same hospital admission 3, 2

Referral to Specialized Centers

Management in, or referral to, a specialist unit is necessary for patients with hemorrhagic/necrotizing pancreatitis. 3, 2

• Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 3, 2
• Specialist centers using aggressive surgical debridement for infected necrosis have reported mortality rates between 10-20%, compared to overall mortality of 30-40% for necrotizing pancreatitis 2
• Patients with infected necrosis should be managed in centers with appropriate endoscopic, radiologic, and surgical expertise 2

Mortality Expectations

• Overall mortality from hemorrhagic/necrotizing pancreatitis is 30-40% 2
• Death occurs an average of 10 days after symptom onset or within 7 days of hospitalization 4
• Approximately one-third of deaths occur in the early phase from multiple organ failure 2
• Most deaths after the first week are due to infected necrosis 2
• Target overall mortality should be lower than 30% in those diagnosed with severe disease 2