How is pancreatitis managed and treated?

Management and Treatment of Acute Pancreatitis

Initial Assessment and Severity Stratification

All patients with severe acute pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support. 1, 2, 3

• Severity should be stratified within 48 hours using clinical impression, APACHE II score, BISAP score, C-reactive protein, or persisting organ failure 3, 4
• Monitoring must include hourly assessment of pulse, blood pressure, central venous pressure (CVP), respiratory rate, oxygen saturation, urine output, and temperature 1, 2, 3
• The etiology should be determined in at least 75-80% of cases to guide treatment and prevent recurrence 5, 3

Fluid Resuscitation

Goal-directed moderate fluid resuscitation with lactated Ringer's solution is recommended over aggressive hydration with normal saline. 3, 6, 7

• Target urine output >0.5 mL/kg body weight per hour 3
• Recent evidence from the WATERFALL trial demonstrates that moderate resuscitation reduces complications compared to aggressive protocols 6, 7
• Avoid aggressive fluid protocols as they increase mortality and complications without improving outcomes 2

Pain Management

Use a multimodal approach with dilaudid as the preferred opioid for non-intubated patients. 2, 3

• Epidural analgesia should be considered for patients requiring high doses of opioids for extended periods or those with moderate to severe pain 2, 3, 6
• Intravenous opiates are generally safe when used judiciously 8
• NSAIDs should be avoided in patients with acute kidney injury 2

Nutritional Support

Early enteral nutrition via nasogastric or nasojejunal tube is strongly recommended over total parenteral nutrition. 1, 2, 3

• Initiate enteral feeding within 24 hours if the patient has no nausea, vomiting, or severe ileus 2, 5, 7
• Both nasogastric and nasojejunal routes are equally effective, with nasogastric feeding successful in approximately 80% of cases 1, 6
• Enteral nutrition prevents gut failure, reduces infectious complications, and decreases mortality 2, 3, 4
• Parenteral nutrition should be reserved only for patients who cannot tolerate enteral feeding or when enteral nutrition is contraindicated 2, 3
• A clear liquid diet is no longer recommended; patients can advance to solid foods as tolerated 5, 6

Antibiotic Management

Prophylactic antibiotics are NOT routinely recommended for acute pancreatitis, including necrotizing pancreatitis. 1, 2, 5, 3

• Antibiotics should only be administered when specific infections are documented (respiratory, urinary, biliary, line-related, or infected necrosis) 1, 2, 3
• If antibiotic prophylaxis is used in severe cases, limit duration to a maximum of 14 days 1, 3
• Cefuroxime or imipenem have been studied, but routine prophylaxis does not prevent infection of pancreatic necrosis 1, 2, 6
• All invasive procedures (ERCP, surgery) require antibiotic prophylaxis 1

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP within 24-72 hours is mandatory for patients with gallstone pancreatitis AND cholangitis, jaundice, or dilated common bile duct. 1, 2, 3

• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1, 3
• ERCP should always be performed under antibiotic cover 1
• Cholecystectomy must be performed during the same hospital admission or within 2-4 weeks after discharge to prevent recurrence. 1, 2, 5, 3
• For mild gallstone pancreatitis, perform cholecystectomy once the patient has recovered, preferably during the same admission 1
• In medically unfit patients, endoscopic sphincterotomy alone may serve as definitive management 1

Common Pitfall to Avoid

Do not perform routine ERCP in all gallstone pancreatitis cases without cholangitis or obstruction—this increases risk without benefit 2. Reserve ERCP for patients with specific indications: cholangitis, persistent jaundice, dilated CBD on ultrasound, or deranged liver function tests 1.

Management of Necrotizing Pancreatitis

Sterile necrosis should be managed conservatively with supportive care; infected necrosis requires intervention but should be delayed until at least 4 weeks after disease onset when possible. 2, 3

Diagnosis of Infected Necrosis

• Suspect infected necrosis in patients with persistent or worsening symptoms after 7-10 days, particularly with fever and signs of sepsis 2
• CT scanning with non-ionic contrast should be obtained 3-10 days after admission for patients with persisting organ failure or clinical deterioration 1, 2, 3
• Image-guided fine needle aspiration should be performed in patients with persistent symptoms and >30% pancreatic necrosis to confirm infection 2

Intervention Strategy

Use a step-up approach starting with percutaneous or endoscopic drainage, progressing to minimally invasive necrosectomy only if no improvement occurs. 2

• Delaying surgery beyond 4 weeks significantly reduces mortality by allowing necrosis to become "walled-off" and demarcated 2
• Minimally invasive techniques are preferred over open necrosectomy when anatomically feasible 2
• Mortality for sterile necrosis is 0-11%; infected necrosis with organ failure carries 35.2% mortality 2, 5

Emergency Indications for Immediate Intervention

• Abdominal compartment syndrome unresponsive to conservative management 2
• Acute ongoing bleeding when endovascular approaches fail 2
• Bowel ischemia or perforation 2
• Acute necrotizing cholecystitis 2

Monitoring for Complications

• Asymptomatic fluid collections should NOT be drained 1
• Maintain strict asepsis with all invasive monitoring equipment to prevent seeding of pancreatic necrosis 3
• Regular arterial blood gas analysis is essential to detect hypoxia and acidosis 3
• Monitor for cholelithiasis development, as it occurs commonly with octreotide use if that agent is employed 9

Specialist Referral

Every hospital receiving acute admissions should have a single nominated clinical team to manage acute pancreatitis. 2, 3

• Refer to specialist centers for extensive necrotizing pancreatitis, infected necrosis requiring intervention, or patients needing intensive therapy, interventional radiology, endoscopic, or surgical procedures 1, 2, 3
• Target overall mortality should be lower than 30% in severe disease; specialist centers report 10-20% mortality for infected necrosis 2

Critical Pitfalls to Avoid

• Do not delay drainage of infected collections—this leads to sepsis and increased mortality 3
• Do not use aggressive fluid resuscitation protocols—moderate goal-directed therapy is superior 2, 6
• Do not routinely use prophylactic antibiotics in mild or severe cases—they do not prevent infection and may cause harm 1, 2, 5, 3
• Do not delay enteral nutrition unnecessarily—early feeding improves outcomes 3, 4, 7
• Do not perform early surgery for necrotizing pancreatitis—delay until at least 4 weeks when possible 2