What is the management of acute pancreatitis in a patient?

From the Guidelines

The management of acute pancreatitis should prioritize early oral feeding within 24 hours as tolerated, enteral nutrition over parenteral nutrition if oral feeding is not possible, and addressing the underlying cause of pancreatitis, such as gallstone removal in biliary pancreatitis, to reduce morbidity, mortality, and improve quality of life.

Key Recommendations

• Initial treatment includes aggressive intravenous fluid resuscitation with lactated Ringer's solution at 5-10 mL/kg/hr in the first 24 hours, with reassessment every 6 hours, as suggested by the American Gastroenterological Association 1.
• Pain control should be achieved with opioid analgesics such as hydromorphone 0.5-1 mg IV every 4-6 hours or morphine 2-4 mg IV every 4 hours.
• Early enteral nutrition within 24-48 hours is recommended, preferably via oral route if tolerated; otherwise, nasojejunal feeding may be necessary, as recommended by the American Gastroenterological Association 1.
• Patients should be kept NPO initially only if experiencing nausea, vomiting, or severe pain.
• Antibiotic prophylaxis is not routinely recommended unless there is confirmed infection or necrotizing pancreatitis, as suggested by the 2019 WSES guidelines for the management of severe acute pancreatitis 1.

Monitoring and Severity Assessment

• Close monitoring of vital signs, urine output, and laboratory values (including lipase, amylase, complete blood count, metabolic panel, and C-reactive protein) is essential.
• Severity assessment using scoring systems like BISAP or Ranson's criteria helps determine if ICU admission is needed.
• The underlying cause should be addressed, such as gallstone removal if biliary pancreatitis is present, to prevent complications like systemic inflammatory response syndrome, pancreatic necrosis, and multi-organ failure, which significantly impact patient outcomes, as highlighted by the American Gastroenterological Association 1 and the 2019 WSES guidelines for the management of severe acute pancreatitis 1.

From the Research

Acute Pancreatitis Management

• The management of acute pancreatitis (AP) involves aggressive hydration, pain management, and nutritional support 2, 3.
• The American College of Gastroenterology guideline recommends that contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically 2.
• Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed, with patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) being admitted to an intensive care unit or intermediary care setting whenever possible 2.

Fluid Resuscitation

• Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidities preclude it, with early aggressive intravenous hydration being most beneficial within the first 12-24 hours 2, 4.
• Lactated Ringer's solution is the preferred fluid type based on animal studies, clinical trials, and meta-analyses, as it reduces systemic inflammation compared with saline in patients with acute pancreatitis 5.
• However, a retrospective study found no significant difference in the outcome of acute pancreatitis between patients receiving lactated Ringer's solution and those receiving normal saline 6.

Nutrition and Antibiotics

• 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, and parenteral nutrition should be avoided 2, 3.
• Routine 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.

Intervention and Drainage

• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension 2.
• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis 2.
• Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours of admission 2, 3.