What is the appropriate management and treatment for an adult patient with suspected pancreatitis, considering both acute and chronic cases, and including those with a history of alcohol use?

Management of Acute Pancreatitis

All patients with acute pancreatitis require immediate aggressive intravenous fluid resuscitation with lactated Ringer's solution, fasting, oxygen supplementation to maintain saturation >95%, and pain control, with treatment intensity determined by severity assessment within the first 24-48 hours. 1, 2

Initial Assessment and Diagnosis

Diagnose acute pancreatitis when two of three criteria are present: 3, 4

• Abdominal pain consistent with pancreatitis
• Serum lipase and/or amylase ≥3 times the upper limit of normal (lipase preferred)
• Characteristic findings on imaging

Immediately establish the etiology through: 5, 2

• Detailed alcohol intake history (quantified in units per week)
• Early ultrasound for gallstones (repeat if initially negative)
• Liver function tests, serum triglycerides, and calcium levels
• Complete medication history including over-the-counter drugs

Severity Stratification (Within 24-48 Hours)

Calculate severity using: 5, 2

• APACHE II score (≥8 indicates severe disease requiring ICU care)
• C-reactive protein at 48 hours (>150 mg/L indicates severity)
• Glasgow score (≥3 indicates severity)

Perform contrast-enhanced CT scan at 72-96 hours (ideally 3-10 days) after symptom onset in all patients with: 5, 1, 2

• Predicted severe disease by scoring systems
• Clinical deterioration or failure to improve
• CT severity index 3-10 requires follow-up scans only if clinical status worsens

Management of Mild Acute Pancreatitis (80% of cases)

Ward-level care with: 5, 2

• Basic monitoring: temperature, pulse, blood pressure, respiratory rate, oxygen saturation, urine output
• Peripheral IV access for fluids
• No routine antibiotics (use only for specific infections: chest, urine, bile, or line-related)
• No routine CT scanning unless clinical deterioration occurs
• Resume oral feeding when pain resolves and patient is hungry

Management of Severe Acute Pancreatitis (20% of cases)

Immediate ICU/HDU admission with intensive monitoring: 5, 1, 2

• Peripheral and central venous access for fluid administration and CVP monitoring
• Urinary catheter for strict output monitoring
• Nasogastric tube
• Hourly vital signs: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, temperature
• Swan-Ganz catheter if cardiocirculatory compromise exists or initial resuscitation fails

Aggressive fluid resuscitation: 5, 1

• Goal-directed therapy with lactated Ringer's solution preferred over normal saline
• Maintain urine output >0.5 ml/kg body weight
• Monitor central venous pressure frequently
• Critical pitfall: Inadequate initial fluid resuscitation is a common fatal error—severe pancreatitis requires massive volume replacement

Antibiotic Prophylaxis (Controversial)

Consider prophylactic antibiotics only for patients with ≥30% pancreatic necrosis on CT: 5, 1, 2

• Use agents that penetrate pancreatic tissue (imipenem/cilastatin, meropenem, or doripenem)
• Limit duration to maximum 14 days to prevent fungal infections and antibiotic resistance
• Do not use routinely in mild pancreatitis
• Reserve antibiotics for documented infections (infected necrosis, pneumonia, urinary tract infection)

Nutritional Support

If nutritional support is required: 1, 2, 6

• Use enteral route (nasogastric or nasojejunal) rather than parenteral nutrition
• Enteral feeding is superior in severe acute pancreatitis, reducing complications including death, multiorgan failure, and systemic infections
• Begin early in severe cases

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP with sphincterotomy within 72 hours of symptom onset if: 1, 2

• Severe pancreatitis with suspected or proven gallstone etiology
• Cholangitis present
• Jaundice or dilated common bile duct
• Failure to improve within 48 hours despite intensive resuscitation

Perform endoscopic sphincterotomy at ERCP whether or not stones are found in the bile duct 2

Definitive cholecystectomy (laparoscopic preferred): 1

• During same hospital admission once patient stabilizes
• Within 2 weeks if discharged
• Critical pitfall: Do not delay ERCP beyond 72 hours in gallstone pancreatitis with severe disease, as this window is critical for preventing complications

Management of Infected Necrosis

Suspect infected necrosis in patients with: 1, 2

• Persistent or worsening symptoms after 7-10 days of illness
• Clinical signs of sepsis with >30% necrosis on CT

Perform image-guided fine needle aspiration (FNA) for culture (accuracy 89-100%) 2, 7

If infected necrosis confirmed: 1, 2, 7

• Complete debridement of all necrotic material required
• Options: surgical necrosectomy, endoscopic necrosectomy, or percutaneous drainage
• Delay necrosectomy as long as possible if patient is stable
• Empiric antibiotics: meropenem, imipenem/cilastatin, or doripenem

Specific Drug Therapy

No proven pharmacological therapy exists for acute pancreatitis: 5

• Antiproteases (gabexate), antisecretory agents (octreotide), and anti-inflammatory agents (lexipafant) have all proven disappointing in large randomized studies
• Aprotinin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have no proven value and cannot be recommended

Ongoing Monitoring and Reassessment

Repeat severity assessment within 48 hours: 7, 6

• Disease condition changes rapidly
• Even initially mild symptoms may progress to severe disease
• Adjust treatment intensity based on clinical trajectory