What is the treatment for a patient with acute pancreatitis, particularly one with a history of gallstones or excessive alcohol consumption, presenting with abdominal pain, nausea, and vomiting?

Treatment for Acute Pancreatitis

For mild acute pancreatitis, initiate moderate fluid resuscitation (preferably Lactated Ringer's), manage pain and nausea, and start early oral feeding within 24 hours—most patients will recover rapidly with this approach alone. 1, 2

Initial Assessment and Severity Stratification

Determine severity within the first 24-48 hours to guide treatment intensity and predict mortality risk 2:

• Mild pancreatitis: No organ failure, local complications, or systemic complications—resolves within the first week 1
• Moderate pancreatitis: Transient organ failure (<48 hours), local complications, or exacerbation of comorbidities 1
• Severe pancreatitis: Persistent organ failure (>48 hours)—carries 15% mortality risk 1, 2

Use clinical impression, obesity status, APACHE II score within 24 hours, C-reactive protein >150 mg/L after 48 hours, or Glasgow score ≥3 to stratify severity 2.

Fluid Resuscitation

Use Lactated Ringer's solution as the fluid of choice, not normal saline, as it significantly reduces systemic inflammation 2. Aggressive fluid resuscitation is critical in the first 48-72 hours to prevent early deaths from circulatory, respiratory, and renal failure 1.

Pain Management and Symptomatic Care

Provide adequate pain control, manage nausea and vomiting, correct electrolyte and metabolic abnormalities, and administer supplemental oxygen as needed 3. Insert a nasogastric tube if there is persistent vomiting 1.

Nutritional Support

Start oral feeding within 24 hours if tolerated—do not keep patients fasting 2. Early feeding reduces the risk of intervention for necrosis by 2.5-fold 2. If oral feeding is not tolerated:

• Use enteral nutrition (nasogastric or nasojejunal tube) rather than parenteral nutrition—effective in 80% of cases and reduces infectious complications 2, 3
• Reserve total parenteral nutrition only for patients who cannot tolerate enteral feeding 3, 4

Monitoring for Severe Disease

All severe cases require HDU or ICU admission with full monitoring 1:

• Peripheral and central venous access for CVP monitoring 1, 2
• Urinary catheter for hourly urine output monitoring 1, 2
• Swan-Ganz catheter if cardiocirculatory compromise exists or initial resuscitation fails 1, 2
• Regular arterial blood gas analysis to detect hypoxia and acidosis 1
• Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 1, 2

CT Imaging

Obtain dynamic CT scan with non-ionic contrast within 3-10 days of admission in patients with persistent organ failure, signs of sepsis, or worsening clinical status 2, 3. Do not perform routine CT scans in mild acute pancreatitis that is improving clinically 2.

Antibiotic Strategy

Do not give routine antibiotic prophylaxis, as high-quality trials show no reduction in infected necrosis or mortality 2. The evidence on prophylactic antibiotics is conflicting 1, 2. If prophylaxis is used in severe cases with substantial necrosis (≥30%), limit to maximum 14 days with intravenous cefuroxime as a reasonable balance between efficacy and cost 1, 2, 3. Reserve antibiotics for documented infections (pneumonia, UTI, cholangitis, line sepsis, or confirmed infected necrosis) 3.

Management of Gallstone Pancreatitis

Urgent ERCP Indications

Perform urgent ERCP with sphincterotomy within 24-72 hours in patients with 1, 2, 5, 3:

• Cholangitis (fever, rigors, positive blood cultures)—this is an immediate indication 1, 5, 3
• Severe pancreatitis with jaundice or dilated common bile duct 1, 5
• Progressive liver dysfunction or increasingly deranged liver function tests 1, 5, 3
• Failure to improve within 48 hours despite intensive resuscitation 1

All ERCP procedures must be performed under antibiotic cover 1, 5, 3. Endoscopic sphincterotomy is required whether or not stones are found in the bile duct 1.

Cholecystectomy Timing

For mild gallstone pancreatitis, perform laparoscopic cholecystectomy during the same hospital admission as soon as the patient has recovered clinically, ideally within 2 weeks and no longer than 4 weeks 1, 5, 3. Delaying beyond 2-4 weeks significantly increases the risk of recurrent biliary events by 56%, including potentially fatal recurrent pancreatitis 5, 3.

For severe gallstone pancreatitis, delay cholecystectomy until signs of lung injury and systemic disturbance have resolved 1.

For patients unfit for surgery, ERCP with sphincterotomy alone provides adequate definitive treatment 1, 5, 3.

Management of Pancreatic Necrosis

Sterile necrosis does not usually require therapy and can be closely monitored unless clinical status deteriorates 2, 5, 3. For patients with >30% pancreatic necrosis and persistent symptoms, or those with smaller areas of necrosis and clinical suspicion of sepsis, perform image-guided fine needle aspiration 7-14 days after onset to obtain material for culture 1, 2.

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2, 5, 3. Delay intervention for 4 weeks when possible to allow wall formation around the necrosis 5. Options include percutaneous drainage, endoscopic ultrasound-guided drainage, or surgical necrosectomy depending on patient acuity and local expertise 6.

Infected necrosis with organ failure carries 35.2% mortality, while sterile necrosis with organ failure has 19.8% mortality 1.

Alcohol-Related Pancreatitis

For alcohol-induced pancreatitis, the same supportive management applies (fluid resuscitation, pain control, early feeding) 1. Counsel patients on complete alcohol cessation to prevent recurrence. There is no role for urgent ERCP in alcohol-related pancreatitis unless concurrent biliary obstruction is suspected.

Critical Pitfalls to Avoid

• Never delay ERCP in patients with cholangitis—this significantly increases morbidity and mortality 2, 5, 3
• Never delay cholecystectomy beyond 2-4 weeks in patients fit for surgery—this dramatically increases recurrent pancreatitis risk 2, 5, 3
• Do not use normal saline for resuscitation—use Lactated Ringer's instead 2
• Do not keep patients fasting—start early oral feeding within 24 hours 2
• Do not use parenteral nutrition when enteral feeding is tolerated 2, 3