What is the appropriate treatment for a patient diagnosed with acute pancreatitis?

Treatment of Acute Pancreatitis

Severity Assessment and Initial Triage

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 ward with basic vital sign monitoring. 1, 2

Severity should be assessed using clinical impression, obesity, APACHE II score in the first 24 hours, C-reactive protein >150 mg/L, Glasgow score ≥3, or persisting organ failure after 48 hours. 1, 2 Patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission require contrast-enhanced CT imaging. 1

Fluid Resuscitation Strategy

Non-aggressive fluid resuscitation at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg (if hypovolemic) is recommended, with Lactated Ringer's solution as the preferred fluid type. 3, 2

The 2023 systematic review found that aggressive intravenous hydration increased mortality risk in severe AP and fluid-related complications in both severe and non-severe AP. 3 Recent evidence demonstrates that non-aggressive protocols result in lower mortality compared to aggressive resuscitation (>10 ml/kg/hr or >250-500 ml/hr). 3

Specific Fluid Protocol:

• Initial bolus: 10 ml/kg in hypovolemic patients or no bolus in normovolemic patients 3
• Maintenance rate: 1.5 ml/kg/hr for the first 24-48 hours 3
• Total volume limit: Less than 4000 ml in the first 24 hours 3
• Fluid type: Lactated Ringer's solution preferred over normal saline due to anti-inflammatory effects and demonstrated reduction in 1-year mortality 3, 4

Monitoring Parameters:

• Urine output target >0.5 ml/kg/hr 1, 3, 2
• Oxygen saturation continuously monitored, maintain >95% with supplemental oxygen 1, 3, 2
• Hematocrit, blood urea nitrogen, creatinine, and lactate levels as markers of tissue perfusion 3, 2
• Central venous pressure in appropriate patients to guide fluid replacement 1, 3

Critical pitfall: Avoid fluid overload, which is associated with worse outcomes, increased mortality, and can precipitate ARDS. 3 If lactate remains elevated after 4L of fluid, do not continue aggressive fluid resuscitation—perform hemodynamic assessment to determine the type of shock. 3

Nutritional Management

Initiate oral feeding immediately rather than keeping patients NPO; advance regular diet as tolerated with appropriate pain management. 2, 5

If oral feeding is not tolerated, enteral nutrition via nasogastric tube is effective in 80% of cases and should be used preferentially over parenteral nutrition. 1, 2, 5 The nasogastric route is as effective as nasojejunal feeding. 2

Pain Management

Pain control is a clinical priority with hydromorphone (Dilaudid) preferred over morphine or fentanyl in non-intubated patients. 2 Consider epidural analgesia as an alternative or adjunct in a multimodal approach for severe cases. 2

Antibiotic Strategy

Do not use prophylactic antibiotics in mild acute pancreatitis or biliary pancreatitis. 2, 5

The evidence on antibiotic prophylaxis is conflicting with no consensus. 1, 5 If prophylactic antibiotics are considered in severe acute pancreatitis with evidence of pancreatic necrosis >30%, limit duration to a maximum of 14 days. 1, 2 Intravenous cefuroxime is a reasonable balance between efficacy and cost if antibiotics are used. 2

Antibiotics should only be administered when specific infections are documented, such as infected necrosis, respiratory, urinary, biliary, or catheter-related infections. 1, 3, 2

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP should be performed within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 1, 2, 5

All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 1, 2 Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction. 1

All patients with biliary pancreatitis should undergo definitive management of gallstones during the same hospital admission, unless a clear plan exists for treatment within two weeks. 1, 5

Management of Pancreatic 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 7-14 days after onset. 2, 5

Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material. 1, 2, 5 The choice of surgical technique for necrosectomy depends on individual features and locally available expertise. 1, 5 Infected necrosis carries 40% mortality. 2

Imaging Strategy

Dynamic contrast-enhanced CT should be performed within 3-10 days in severe cases to identify pancreatic necrosis, using non-ionic contrast. 2 Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 2, 5

Referral Criteria

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or complications requiring ICU care, or interventional radiological, endoscopic, or surgical procedures. 1, 2

Discontinuation of IV Fluids

Discontinue IV fluids when the patient demonstrates resolution of pain and can tolerate oral intake. 3 In mild pancreatitis, IV fluids can typically be discontinued within 24-48 hours. 3 Progressively wean IV fluids rather than stopping abruptly to prevent rebound hypoglycemia. 3