What is the management approach for a patient with acute pancreatitis?

Management of Acute Pancreatitis

All patients with acute pancreatitis require immediate aggressive fluid resuscitation and oxygen supplementation within the first 12-24 hours, as this is the single most critical intervention to prevent organ failure and reduce mortality. 1, 2

Initial Assessment and Diagnosis

Diagnose acute pancreatitis when two of three criteria are present: upper abdominal pain, serum amylase or lipase elevation ≥3 times upper limit of normal, and characteristic imaging findings. 2, 3

• The correct diagnosis should be made within 48 hours of admission in all patients. 4
• Determine the etiology in at least 80% of cases—no more than 20% should remain classified as idiopathic. 4, 5
• Perform early ultrasound examination of the gallbladder within 24 hours to identify biliary causes. 4, 5

Severity Stratification (Within 48 Hours)

Complete severity assessment within 48 hours using: clinical impression of severity, obesity, APACHE II score in first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persistent organ failure after 48 hours. 4, 5

Disease Classification and Expected Mortality:

• Mild pancreatitis (80% of cases): <5% mortality, self-limiting course 5
• Severe pancreatitis (20% of cases): 15% hospital mortality, accounts for 95% of deaths 5
• Infected necrosis with organ failure: 35.2% mortality 1, 5
• Sterile necrosis with organ failure: 19.8% mortality 1, 5
• Infected necrosis without organ failure: 1.4% mortality 1, 5

Immediate Resuscitation and Monitoring

Oxygen Therapy:

• Administer supplemental oxygen to maintain arterial saturation >95%. 4, 2
• Measure oxygen saturation continuously in all patients. 4, 2

Fluid Resuscitation:

Use Lactated Ringer's solution as the preferred crystalloid—avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure. 1, 5

• Target urine output >0.5 ml/kg body weight. 4, 1, 2, 5
• Monitor fluid replacement rate by frequent measurement of central venous pressure in appropriate patients. 4, 2
• Early aggressive intravenous hydration is most beneficial within the first 12-24 hours and may have little benefit beyond this window. 2, 3
• Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion. 1

Monitoring Requirements:

For mild cases: hourly vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation, urine output). 1, 5

For severe cases: continuous vital signs monitoring in high dependency unit or intensive care unit with full monitoring and systems support. 4, 2

Pain Management

Pain control is a clinical priority requiring aggressive management—use Dilaudid as preferred agent over morphine or fentanyl in non-intubated patients. 1

• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach. 1, 2, 5
• Integrate patient-controlled analgesia (PCA) with every pain management strategy. 1, 2
• Avoid NSAIDs in patients with acute kidney injury. 1

Nutritional Support

In mild pancreatitis, initiate early oral feeding within 24 hours as tolerated—do not enforce fasting. 1, 2, 5

When nutritional support is required, enteral nutrition is strongly preferred over parenteral nutrition to prevent gut failure and infectious complications. 4, 1, 2, 5

• Both nasogastric and nasojejunal routes are acceptable and safe for enteral nutrition—nasogastric feeding is effective in 80% of cases. 4, 1, 2
• If ileus persists for more than 5 days, parenteral nutrition will be required. 1
• Avoid parenteral nutrition in severe acute pancreatitis when enteral route is tolerated. 3

Antibiotic Therapy

Prophylactic antibiotics are NOT routinely recommended in patients with predicted severe acute pancreatitis and necrotizing pancreatitis—the evidence is conflicting and there is no consensus. 4, 5

When Antibiotics ARE Indicated:

• Specific infections occur (respiratory, urinary tract, biliary, or catheter-related). 1
• Clinical suspicion of infected necrosis with positive cultures. 4, 2

If Prophylactic Antibiotics Are Used:

• Maximum duration should be 14 days in the absence of positive cultures. 4, 2
• Intravenous cefuroxime provides reasonable balance between efficacy and cost. 2, 5

Assessment for Infected Necrosis:

All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration (FNA) for culture 7-14 days after onset. 4, 1, 2

Imaging Strategy

Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 1, 5

When to Obtain CT:

Patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission require computed tomography. 4

• Use contrast-enhanced CT with non-ionic contrast (100 ml at 3 ml/s) with thin collimation (≤5 mm) through pancreatic bed. 4
• Images should be obtained approximately 40 seconds after injection start. 4
• Non-opacification of at least one-third of the pancreas, or an area >3 cm diameter, indicates necrosis. 4
• CT without intravenous contrast enhancement gives suboptimal information and should be avoided. 4

Follow-up CT:

• Patients with mild pancreatitis or CT severity index 0-2 require further CT only if clinical status changes suggesting new complication. 4, 1
• Patients with CT severity index 3-10 need additional scans only if clinical status deteriorates or fails to show continued improvement. 4

Management of Biliary Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 4, 2, 5

• In patients with acute cholangitis, ERCP must be performed within 24 hours. 3
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 4
• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction. 4

Cholecystectomy Timing:

All patients with biliary pancreatitis should undergo cholecystectomy during the same hospital admission, unless a clear plan for definitive treatment within the next 2 weeks has been made. 4, 2

• For unfit patients, endoscopic sphincterotomy alone is adequate treatment. 4, 1
• Delay cholecystectomy in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved. 1

Management of Pancreatic Necrosis

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 4, 2

Infected Necrosis:

Infected necrosis is the most serious local complication with 40% mortality rate. 4, 1

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 4, 1, 5

Timing and Approach to Intervention:

In stable patients with infected necrosis, delay surgical, radiologic, or endoscopic drainage for 4 weeks when possible to allow wall formation around necrosis—this reduces mortality. 2, 3

• Consider minimally invasive approaches (percutaneous drainage, endoscopic drainage) before open surgical necrosectomy. 1, 2, 5
• Use a step-up approach: start with percutaneous or endoscopic drainage, then consider minimally invasive surgical strategies if drainage fails. 2
• The choice of surgical technique for necrosectomy and subsequent postoperative management depends on individual features and locally available expertise. 4

Organizational Requirements

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 4, 2, 5

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or with other complications who may require intensive care, or interventional radiological, endoscopic, or surgical procedures. 4, 2

Required Facilities:

• Radiological facilities for ultrasound examination of gallbladder within 24 hours of diagnosis. 4
• Access to contrast-enhanced helical or multislice CT or MRI at any time. 4
• Facilities and expertise for ERCP at any time with sphincterotomy and stone extraction or stenting. 4, 2
• Percutaneous image-guided aspiration and drainage techniques. 4
• Multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists. 1, 5

Common Pitfalls to Avoid

• Do not use hydroxyethyl starch fluids—they increase multiple organ failure risk. 1, 5
• Do not routinely administer prophylactic antibiotics in mild pancreatitis—no evidence of benefit. 5
• Do not delay drainage of infected collections—leads to sepsis and increased mortality. 5
• Do not perform CT without intravenous contrast—gives suboptimal information. 4
• Do not enforce fasting in mild pancreatitis—early oral feeding is beneficial. 1, 2, 5
• Do not use parenteral nutrition when enteral route is tolerated—increases infectious complications. 1, 2, 5
• Do not delay cholecystectomy beyond index admission in biliary pancreatitis—significant risk of recurrent severe pancreatitis. 4, 1

Expected Outcomes

• Overall mortality should be <10%. 4, 2
• Severe (complicated) pancreatitis mortality should be <30%. 4, 2