What are the causes and symptoms of acute pancreatitis?

From the Guidelines

Acute pancreatitis requires prompt medical attention, and the most recent guidelines recommend early fluid resuscitation, pain management, and bowel rest, with a focus on identifying and addressing the underlying cause, such as gallstones or alcohol, to improve morbidity, mortality, and quality of life outcomes. The diagnosis of acute pancreatitis should be established within 48 hours of admission, based on compatible clinical features and elevations in amylase or lipase levels, with elevations greater than 3 times the upper limit of normal being most consistent with acute pancreatitis 1. The management of acute pancreatitis involves:

• Early fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr in the first 24 hours to prevent complications
• Pain management with medications like morphine (2-4mg IV every 4 hours as needed) or hydromorphone (0.5-1mg IV every 4 hours as needed)
• Bowel rest, with patients receiving nothing by mouth (NPO) until pain improves and inflammatory markers decrease
• Identification and addressing of the underlying cause, such as gallstones or alcohol, with cholecystectomy recommended for gallstone pancreatitis during the same hospitalization once inflammation subsides, and alcohol cessation essential for alcohol-induced pancreatitis
• Enteral nutrition is preferred over parenteral nutrition, with oral, NG, or NJ feeding options, and parenteral nutrition used only if enteral nutrition is not tolerated 1
• Prophylactic antibiotics are not recommended for all patients with acute pancreatitis, but are recommended for patients with infected severe acute pancreatitis, with diagnosis challenging due to clinical picture, and CT- or EUS-guided fine-needle aspiration (FNA) for Gram stain and culture, and endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute biliary pancreatitis and common bile duct obstruction, should be performed as soon as possible 1. Severe cases require more aggressive management, possibly including antibiotics, and may need intensive care monitoring, with patients who have persistent organ failure with infected necrosis having the highest risk of death, and patients with organ failures should be admitted to an intensive care unit whenever possible 1. The ESPEN guideline on clinical nutrition in acute and chronic pancreatitis recommends that patients with chronic pancreatitis should be considered at risk, screened, and supplemented accordingly, with osteoporosis and increased fracture risk acknowledged, and preventive measures considered 1. Overall, the management of acute pancreatitis requires a comprehensive approach, with a focus on early recognition, fluid resuscitation, pain management, bowel rest, and identification and addressing of the underlying cause, to improve morbidity, mortality, and quality of life outcomes.

From the Research

Definition and Diagnosis of Acute Pancreatitis

• Acute pancreatitis is a common indication for hospital admission, with increasing incidence in various populations, including children, pregnancy, and the elderly 2.
• The diagnosis of acute pancreatitis requires two of the following: upper abdominal pain, amylase/lipase ≥ 3 × upper limit of normal, and/or cross-sectional imaging findings 2.

Treatment and Management of Acute Pancreatitis

• Initial priorities in the treatment of acute pancreatitis include intravenous fluid resuscitation, analgesia, and enteral nutrition 2.
• The use of intravenous fluid resuscitation remains a cornerstone in the early treatment of acute pancreatitis, with Lactated Ringer's solution being the preferred fluid type 3, 4.
• However, the optimal timing, fluid type, volume, rate, and duration of fluid resuscitation in acute pancreatitis are still unclear, with some studies suggesting that aggressive fluid resuscitation may be associated with higher mortality 5.
• Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications, but the optimal type and rate of fluid resuscitation have yet to be determined 6.

Complications and Prognosis of Acute Pancreatitis

• Acute pancreatitis can cause substantial morbidity and mortality, particularly in cases of severe disease with persistent organ failure 2.
• The development of local complications, such as fluid and/or necrotic collections, requires referral to specialist tertiary centers for further management, which may include drainage and/or necrosectomy 2.
• The impact of acute pancreatitis can be devastating, and prevention or reduction of the risk of recurrence and progression to chronic pancreatitis requires proactive management that should be long term for some patients 2.

Fluid Resuscitation Strategies

• The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate fluid resuscitation strategies 4.
• A meta-analysis of 6 RCTs involving 632 patients found that aggressive fluid resuscitation increased the risk of all-cause mortality compared to moderate fluid replacement 5.
• However, there is still a lack of high-quality data to support the use of early aggressive fluid resuscitation, and large, well-designed, multicenter randomized controlled trials are needed to determine the optimal fluid resuscitation strategy 3, 4.