What is the treatment approach for acute pancreatitis?

Treatment of Acute Pancreatitis

Initial Triage and Monitoring

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

• Severe disease represents only 20% of cases but carries 95% of mortality, whereas mild disease accounts for 80% of cases with less than 5% mortality. 1
• For severe cases, continuous vital signs monitoring including oxygen saturation is mandatory, with regular arterial blood gas analysis to detect hypoxia and acidosis early. 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess tissue perfusion throughout the course of treatment. 1

Fluid Resuscitation

Use goal-directed moderate fluid resuscitation with Lactated Ringer's solution, targeting urine output >0.5 ml/kg body weight per hour. 1, 3

• Avoid aggressive fluid resuscitation, as moderate goal-directed therapy is preferred over excessive volume administration. 1
• Early aggressive fluid resuscitation in the first 48-72 hours is critical to prevent morbidity and mortality. 4, 5

Nutrition Management

Initiate oral feeding immediately rather than keeping patients NPO, and advance regular diet as tolerated. 1

• The outdated practice of "gut rest" to decrease pancreatic stimulation has been revised—early enteral feeding is safe and beneficial when tolerated. 2
• If oral feeding is not tolerated, use enteral nutrition (NG or NJ feeding) rather than parenteral nutrition, as enteral nutrition is associated with lower rates of death, multiorgan failure, and systemic infections. 5

Pain Management

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

• Consider epidural analgesia as an adjunct in a multimodal approach for severe pain in intensive care settings. 1
• Routinely prescribe laxatives to prevent opioid-induced constipation. 2
• Use metoclopramide for opioid-related nausea and vomiting. 2

Antibiotic Use

Prophylactic antibiotics should not be used in mild pancreatitis and are not recommended for routine use even in severe pancreatitis. 1, 2

• If antibiotics are used in severe pancreatitis with evidence of pancreatic necrosis >30%, limit duration to a maximum of 14 days. 1
• Reserve antibiotics only for treating confirmed infected severe acute pancreatitis, not for prophylaxis. 2
• Procalcitonin is the most sensitive test for detecting pancreatic infection; antibiotics should only be given for confirmed infections. 2

Imaging Strategy

Perform dynamic CT scanning with non-ionic contrast within 3-10 days of admission. 1

• Obtain CT for patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission. 1
• Contrast-enhanced CT is the diagnostic standard for evaluating acute pancreatitis severity and prognosis. 5
• Peripancreatic fluid on CT occurs in 30-50% of severe cases and resolves spontaneously in more than half of cases. 2

Management of Gallstone Pancreatitis

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

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 6
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction. 6

Definitive Biliary Management

All patients with biliary pancreatitis should undergo cholecystectomy during the same hospital admission, unless a clear plan exists for treatment within two weeks. 1

• Definitive treatment should not be delayed more than two weeks after discharge to avoid potentially fatal recurrent acute pancreatitis. 6
• Cholecystectomy should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved. 6

Management of Pancreatic Necrosis

Assessment for Infection

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

• The accuracy of FNA is reported to be 89-100% for detecting infected necrosis. 7
• A small number of patients with infected necrosis have been shown to recover with antibiotics only, though this is uncommon. 6

Intervention Strategy

When infected necrosis is confirmed in a symptomatic patient, use a step-up approach starting with percutaneous or endoscopic drainage as first-line treatment. 6, 1

• Percutaneous drainage as the first line of treatment delays surgical treatment to a more favorable time or results in complete resolution of infection in 25-60% of patients. 6
• Minimally invasive surgical strategies, such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD), result in less postoperative new-onset organ failure but require more interventions. 6

Timing of Surgical Intervention

Postpone surgical interventions for more than 4 weeks after the onset of disease, as delayed surgery results in less mortality. 6

• With delayed surgery, demarcation of necrosis from vital tissue occurs, resulting in less bleeding and more effective necrosectomy. 6
• A majority of patients with sterile necrotizing pancreatitis can be managed without interventions. 6
• However, interventions should be considered when organ dysfunctions persist for more than 4 weeks, as nearly half of patients operated for ongoing organ failure without signs of infected necrosis have positive bacterial cultures. 6

Indications for Surgical Intervention

Surgical intervention is indicated for:

• Continuation in a step-up approach after percutaneous/endoscopic procedure failure with the same indications. 6
• Abdominal compartment syndrome (after conservative methods fail, surgical decompression by laparostomy should be considered). 6
• Acute ongoing bleeding when endovascular approach is unsuccessful. 6
• Bowel ischemia or acute necrotizing cholecystitis during acute pancreatitis. 6
• Bowel fistula extending into a peripancreatic collection. 6

Management of Sterile Necrosis

• Walled-off necrotic collections or pseudocysts that cause symptoms and/or mechanical obstruction require a step-up approach if they do not resolve when inflammation ceases. 6
• A symptomatic disconnected pancreatic duct resulting in a peripancreatic collection is an indication for interventions. 6

Common Pitfalls to Avoid

• Do not perform emergency surgery within the first 4 weeks unless absolutely necessary (abdominal compartment syndrome, bowel necrosis, uncontrolled bleeding), as early surgery significantly increases mortality. 6
• Do not use aggressive fluid resuscitation—moderate goal-directed therapy is superior and prevents fluid overload complications. 1
• Do not keep patients NPO routinely—the old paradigm of pancreatic rest has been abandoned in favor of early oral feeding. 1, 2
• Do not delay cholecystectomy beyond two weeks in mild gallstone pancreatitis—the risk of recurrent potentially fatal pancreatitis is significant. 6, 1
• Do not use prophylactic antibiotics routinely—they do not decrease mortality or morbidity and should be reserved for confirmed infections only. 1, 2