What is the recommended treatment for a patient with acute pancreatitis?

Management of Acute Pancreatitis

Immediate Severity Assessment and Triage

All patients with severe acute pancreatitis must be managed in an intensive care unit or high dependency unit with full monitoring and systems support, while mild cases can be managed on a general medical ward. 1

• Classify severity immediately upon presentation, as this determines the entire treatment approach—severe disease carries 95% of mortality and requires aggressive intervention, while mild disease has <5% mortality and needs only supportive measures 2
• Use clinical impression, obesity, APACHE II score in first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours to predict severity 1
• Severe cases require peripheral venous access, central venous line for fluid administration and CVP monitoring, urinary catheter, and nasogastric tube 3, 2

Fluid Resuscitation Strategy

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive fluid resuscitation. 1, 2

• Target urine output >0.5 ml/kg body weight 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion 1, 2
• Early aggressive intravenous hydration is most beneficial within the first 12-24 hours and may have little benefit beyond 4
• Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 3, 2

Common Pitfall: Aggressive fluid resuscitation is no longer recommended—moderate resuscitation has proven superior outcomes. 5

Nutritional Management

Initiate oral feeding immediately in mild pancreatitis rather than keeping patients NPO. 1, 2

• Advance regular diet as tolerated with appropriate pain management in mild cases 1, 2
• In severe pancreatitis, provide enteral nutrition via nasogastric or nasoenteral tube if oral feeding is not tolerated 1, 2
• The nasogastric route is effective in 80% of cases and is as effective as the nasojejunal route 1, 6
• Use parenteral nutrition only when enteral nutrition is inadequate or caloric goals cannot be met enterally 2

Common Pitfall: Keeping patients NPO when they can tolerate oral feeding is outdated practice and should be avoided. 1

Pain Management

Use Dilaudid as the preferred opioid over morphine or fentanyl in non-intubated patients. 1, 2

• Consider epidural analgesia as an alternative or adjunct in a multimodal approach for severe cases 1, 2
• Pain control should be a clinical priority 1

Antibiotic Strategy

Do not use prophylactic antibiotics in mild acute pancreatitis or biliary pancreatitis. 1, 2, 6

• Consider prophylactic antibiotics only in severe acute pancreatitis with evidence of pancreatic necrosis >30% 1, 2, 6
• If antibiotics are used, intravenous cefuroxime represents a reasonable balance between efficacy and cost 3, 1, 2
• Limit duration to a maximum of 14 days 1, 6
• Always perform ERCP under antibiotic cover 3, 2

Common Pitfall: Routine use of antibiotics in mild pancreatitis has no proven benefit and should be avoided. 1, 6

Imaging Strategy

Perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days in severe cases to identify pancreatic necrosis. 3, 1, 2

• Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs 2, 6
• Reserve contrast-enhanced CT and/or MRI for patients in whom the diagnosis is unclear or who fail to improve clinically 4

Common Pitfall: Overuse of CT scanning in mild cases with clinical improvement wastes resources and exposes patients to unnecessary radiation. 1, 6

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 3, 1, 2, 6

• Patients with acute cholangitis require ERCP within 24 hours of admission 4, 7
• If the patient's condition fails to improve within 48 hours despite intensive resuscitation, proceed with urgent ERCP and sphincterotomy 3, 2
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1, 2
• Immediate therapeutic ERCP is required with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 3, 2
• For mild gallstone pancreatitis, perform laparoscopic cholecystectomy within two to four weeks, preferably during the same hospital admission 3, 6

Common Pitfall: Delaying ERCP in severe gallstone pancreatitis with cholangitis significantly increases morbidity and mortality. 1, 6

Management of Pancreatic Necrosis

Perform image-guided fine needle aspiration 7-14 days after onset for patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas and clinical suspicion of sepsis. 1, 2, 6

• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2, 6
• In stable patients with infected necrosis, delay surgical, radiologic, and/or endoscopic drainage for preferably 4 weeks to allow development of a wall around the necrosis 4
• Infected necrosis carries 40% mortality 1
• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, or extension 4

Monitoring Requirements

For severe cases, monitor hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature. 3, 2

• Maintain continuous oxygen saturation monitoring with supplemental oxygen to keep saturation >95% 1, 2
• When cardiocirculatory compromise exists or initial resuscitation fails, use Swan-Ganz catheter for measurement of pulmonary artery wedge pressure, cardiac output, and systemic resistance 3
• Observe strict asepsis in placement and care of invasive monitoring equipment, as these may serve as a source of subsequent sepsis in the presence of pancreatic necrosis 3