From the Guidelines
Pancreatitis management should prioritize supportive care, including intravenous fluids, pain control, and bowel rest, with a focus on determining the etiology to guide specific treatment, as recommended by the most recent guidelines 1.
Overview of Pancreatitis
Pancreatitis is inflammation of the pancreas that can occur as acute or chronic forms. Acute pancreatitis typically presents with severe abdominal pain, nausea, and vomiting, often requiring hospitalization for management.
Determining Etiology
The etiology of acute pancreatitis should be established in at least three-fourths of patients, focusing on history of gallstones, alcohol use, hypertriglyceridemia, hypercalcemia, family history of pancreatic disease, and prescription or nonprescription drug history, as outlined in the AGA Institute medical position statement 1.
Treatment Approach
Treatment focuses on supportive care including:
- Intravenous fluids
- Pain control with medications like morphine or hydromorphone
- Bowel rest Patients should avoid oral intake initially until pain improves, then gradually advance to a low-fat diet.
Chronic Pancreatitis Management
Chronic pancreatitis involves ongoing inflammation leading to permanent damage and requires long-term management including:
- Pancreatic enzyme replacement therapy (such as Creon 24,000-36,000 units with meals)
- Pain management
- Nutritional support
Lifestyle Modifications
Lifestyle modifications are essential, particularly:
- Complete alcohol cessation
- Smoking cessation, as these significantly worsen outcomes.
Severe Acute Pancreatitis
Patients with severe acute pancreatitis may require intensive care monitoring due to potential systemic complications including respiratory failure and kidney injury, as highlighted in the 2019 WSES guidelines for the management of severe acute pancreatitis 1.
Key Recommendations
- All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 1.
- Urgent therapeutic ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who satisfy the criteria for predicted or actual severe pancreatitis, or when there is cholangitis, jaundice, or a dilated common bile duct 1.
From the Research
Pancreatitis Prevention and Treatment
- Pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP) 2
- Aggressive hydration with lactated Ringer's solution has been shown to reduce the incidence of post-ERCP pancreatitis 2, 3
- The use of lactated Ringer's solution in combination with rectal indomethacin has also been found to be effective in preventing post-ERCP pancreatitis and reducing readmission rates 4
Risk Factors and Diagnosis
- Eighty percent of acute pancreatitis episodes are related to gallstones or alcohol abuse 5
- The diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels, and/or characteristic findings on computed tomography 5
- Endoscopic retrograde cholangiopancreatography is recommended as a causative therapy in patients with acute cholangitis or a strong suspicion of gallstones 5
Treatment and Management
- Vigorous fluid resuscitation and supplemental oxygen therapy are important in the management of acute pancreatitis 5
- Enteral nutrition is preferred over parenteral nutrition, with the majority favoring the nasojejunal route 5
- Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis 5
- Infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy, while sterile pancreatic necrosis should be managed conservatively 5
Comparison of Hydration Solutions
- A study comparing aggressive normal saline versus lactated Ringer's solution for the prevention of post-ERCP pancreatitis found a lower incidence of pancreatitis in the lactated Ringer's group, although the difference was not statistically significant 6
- Another study found that aggressive hydration with lactated Ringer's solution was the best approach to intravenous hydration for the prevention of post-ERCP pancreatitis in average-to-high risk patients 3