What is the management of acute pancreatitis in a patient?

From the Guidelines

The management of acute pancreatitis should prioritize goal-directed fluid therapy, early oral feeding, and enteral nutrition, as recommended by the American Gastroenterological Association 1. The initial management of acute pancreatitis involves a comprehensive approach focusing on supportive care, pain control, and prevention of complications.

Key Components of Management

• Fluid Resuscitation: The use of goal-directed therapy for fluid management is suggested, with no specific recommendation for the type of fluid to be used, such as normal saline or Ringer’s lactate 1.
• Pain Control: Opioid analgesics such as hydromorphone or morphine can be used to achieve adequate pain control.
• Nutritional Support: Early oral feeding, within 24 hours, is recommended as tolerated, rather than keeping the patient nil per os 1. If oral intake is not possible, enteral nutrition is preferred over parenteral nutrition.
• Antibiotic Use: Prophylactic antibiotics are not recommended for patients with predicted severe AP and necrotizing AP, unless there is evidence of infection 1.
• ERCP: Urgent ERCP is not recommended for patients with acute biliary pancreatitis and no cholangitis, but it may be indicated for those with concurrent cholangitis or biliary obstruction.

Addressing Underlying Causes

The underlying cause of acute pancreatitis, such as gallstones or alcohol, should be addressed to prevent recurrence.

• Cholecystectomy: For patients with acute biliary pancreatitis, cholecystectomy is recommended during the initial admission rather than after discharge 1.
• Alcohol Intervention: Brief alcohol intervention is recommended for patients with acute alcoholic pancreatitis during admission 1.

Monitoring and Complications

Close monitoring for complications like pseudocysts, necrosis, or organ failure is essential, and the management plan should be adjusted accordingly. The most recent and highest quality study on the comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis suggests that aggressive hydration may increase the risk of fluid overload and mortality in non-severe AP 1. However, the American Gastroenterological Association guidelines prioritize goal-directed fluid therapy, and the choice of fluid type and rate should be individualized based on the patient's condition and response to treatment 1.

From the Research

Acute Pancreatitis Management

• The management of acute pancreatitis (AP) involves several key components, including fluid resuscitation, nutritional support, and the management of complications 2.
• Aggressive hydration is recommended for all patients with AP, unless cardiovascular and/or renal comorbidities preclude it, with lactated Ringer's solution being a preferred choice over normal saline due to its ability to reduce systemic inflammation 3, 4, 5.
• Early enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided 2, 6.
• The use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended, but antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention in patients with infected necrosis 2.

Fluid Resuscitation

• Lactated Ringer's solution has been shown to reduce systemic inflammation compared to normal saline in patients with AP 3, 4, 5.
• A systematic review and meta-analysis found that lactated Ringer's solution was associated with a lower risk of moderate-to-severe AP, a shorter hospital stay, and a reduced ICU admission rate compared to normal saline 4.
• The choice of fluid type may affect outcomes in critically-ill patients with AP, with lactated Ringer's solution potentially having a survival benefit over isotonic saline 5.

Nutritional Support

• Early aggressive intravenous hydration is most beneficial within the first 12-24 hours, and may have little benefit beyond 2.
• In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, while in severe AP, enteral nutrition is recommended to prevent infectious complications 2, 6.
• The underlying etiology of AP should be sought in all patients, and risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for AP 6.

Complications Management

• Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours of admission 2.
• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension, but surgical, radiologic, and/or endoscopic drainage should be delayed in stable patients with infected necrosis, preferably for 4 weeks, to allow the development of a wall around the necrosis 2.