How should acute pancreatitis be managed, including fluid resuscitation, analgesia, nutrition, severity assessment, and cause‑specific interventions?

Management of Acute Pancreatitis

Aggressive early fluid resuscitation and oxygen supplementation within the first 12-24 hours are the most critical interventions to prevent organ failure and reduce mortality in acute pancreatitis. 1

Initial Assessment and Diagnosis

Diagnosis requires two of three criteria:

• Upper abdominal pain characteristic of pancreatitis
• Serum lipase or amylase ≥3 times the upper limit of normal (lipase is preferred with 79% sensitivity and 89% specificity)
• Characteristic imaging findings of pancreatic inflammation 1, 2, 3

Immediate laboratory evaluation should include:

• Serum triglycerides, complete blood count, renal and liver function tests
• Glucose, calcium, C-reactive protein
• Right upper quadrant ultrasound within 24 hours to evaluate for gallstones 1, 4

Severity Stratification

Complete severity assessment within 48 hours using validated scoring systems such as BISAP (Bedside Index of Severity in Acute Pancreatitis) or APACHE II (cutoff ≥8 predicts severe disease). 1, 2

Key severity markers include:

• C-reactive protein ≥150 mg/L at 48 hours
• Hematocrit >44%
• Blood urea nitrogen >20 mg/dL
• Persistent organ failure despite adequate resuscitation 1, 2

Expected mortality benchmarks:

• Overall mortality should be <10%
• Severe acute pancreatitis mortality should be <30%
• One-third of deaths occur in the first week from multiple organ failure
• Two-thirds occur after the first week from infected necrosis 1, 5

Initial Resuscitation and Monitoring

Oxygen supplementation:

• Administer supplemental oxygen to maintain arterial saturation >95%
• Monitor oxygen saturation continuously 6, 1

Fluid resuscitation:

• Target urine output >0.5 mL/kg body weight
• Monitor central venous pressure frequently to guide fluid rate in appropriate patients
• Critical caveat: Recent evidence suggests more cautious fluid resuscitation in the first 24 hours may be more appropriate for some patients, as overly aggressive protocols increase mortality and complications 1, 3, 7

Monitoring requirements:

• Hourly vital signs including pulse, blood pressure, respiratory rate, oxygen saturation, urine output, and temperature
• Serial hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of tissue perfusion 1, 5

All patients with severe acute pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 1, 5

Pain Management

Use a multimodal approach for pain control:

• Intravenous opioids (such as dilaudid) are safe when used judiciously
• Patient-controlled analgesia (PCA) should be integrated with every pain management strategy
• Epidural analgesia may be considered as an alternative or adjunct for patients requiring high doses of opioids for extended periods 1, 5, 3

Avoid NSAIDs in patients with acute kidney injury. 5

Nutritional Support

Early enteral nutrition is superior to parenteral nutrition and should be initiated within 24 hours if the patient has no nausea, vomiting, or signs of severe ileus. 6, 1, 5

For mild-to-moderate pancreatitis:

• Fasting for 2-5 days initially with IV fluid and electrolyte replacement
• Refeeding on days 3-7 with a diet rich in carbohydrates, moderate in protein, and moderate in fat
• Progress to normal diet as tolerated 6

For severe pancreatitis:

• Early enteral feeding via nasogastric or nasojejunal tube (both routes are safe)
• Enteral nutrition prevents gut failure and infectious complications
• If enteral nutrition is inadequate or not tolerated, parenteral nutrition should be used
• Many patients will require a combination of enteral and parenteral nutrition 6, 1

Important caveat: Twenty-one percent of patients experience pain relapse during oral refeeding, with half occurring on days 1-2. Patients with serum lipase three times the upper limit and higher CT-Balthazar scores have more frequent pain relapses. 6

Antibiotic Therapy

Prophylactic antibiotics are NOT routinely recommended for mild pancreatitis or for prevention of pancreatic necrosis infection. 1, 5, 7

Antibiotics should only be used when specific infections are documented:

• Infected necrosis
• Cholangitis
• Respiratory infections
• Urinary tract infections 1, 5

If antibiotics are used in severe pancreatitis with pancreatic necrosis:

• Intravenous cefuroxime provides a reasonable balance between efficacy and cost
• Maximum duration should be 14 days in the absence of positive cultures 6, 1

The evidence on prophylactic antibiotics remains controversial: Meta-analyses suggest possible reduction in complications and deaths, but studies show significant heterogeneity with different antibiotics, durations, and endpoints. 6

CT Imaging

Dynamic CT with IV contrast should be obtained within 3-10 days in severe cases to assess pancreatic necrosis and guide prognosis. 1, 5

Use CT severity index scoring to assess disease severity (combines inflammation and necrosis assessment, correlates with morbidity and mortality). 1, 2

Follow-up CT indications:

• Patients with mild pancreatitis or CT severity index 0-2 require further CT only if clinical status changes
• Patients with CT severity index 3-10 need additional scans only if clinical status deteriorates or fails to improve
• Consider a single scan before discharge in apparently uncomplicated recovery to detect asymptomatic complications (pseudocyst, arterial pseudoaneurysm) 6, 1

Avoid CT without IV contrast as it provides suboptimal information. 6

Management of Gallstone Pancreatitis

Urgent ERCP within 24-72 hours is indicated for:

• Concomitant cholangitis
• Jaundice
• Dilated common bile duct 1, 5, 2

Cholecystectomy should be performed during the same hospital admission for all patients with biliary pancreatitis, or a clear plan for definitive treatment within 2 weeks must be established. 1, 5, 7

Same-admission cholecystectomy decreases length of hospital stay and complication rates. 8, 7

Management of Pancreatic Necrosis

For sterile necrosis:

• Conservative management with focus on fluid resuscitation, nutritional support, and monitoring for complications
• Mortality rate is 0-11% 1, 5

For suspected infected necrosis:

• Suspect in patients with persistent or worsening symptoms after 7-10 days of illness
• All patients with persistent symptoms and >30% pancreatic necrosis should undergo image-guided fine needle aspiration (accuracy 89-100%) 1, 5, 9

Management of confirmed infected necrosis:

• Delay intervention until at least 4 weeks after disease onset when possible to allow wall formation around necrosis, reducing mortality
• Use a step-up approach: start with percutaneous or endoscopic drainage, progress to minimally invasive necrosectomy if no improvement
• Minimally invasive techniques are preferred over open necrosectomy when anatomically feasible 1, 5, 7

Emergency indications for early intervention (<4 weeks):

• Abdominal compartment syndrome unresponsive to conservative management
• Acute ongoing bleeding when endovascular approach fails
• Bowel ischemia or perforation
• Acute necrotizing cholecystitis 5

Mortality with infected necrosis:

• Average 40%, can exceed 70%
• With organ failure: 35.2% mortality
• Specialist centers using aggressive surgical debridement report 10-20% mortality 5, 2

Organizational Requirements

Every hospital receiving acute admissions must have:

• A single nominated clinical team to manage all acute pancreatitis patients
• Facilities for 24-hour ERCP with sphincterotomy and stone extraction/stenting
• Radiological facilities permitting ultrasound examination of the gallbladder within 24 hours 1

Referral to a specialist unit is necessary for:

• Extensive necrotizing pancreatitis
• Complications requiring intensive care
• Need for interventional radiology, endoscopy, or surgery
• Patients requiring a multidisciplinary specialist pancreatic team 1, 5

Critical Pitfalls to Avoid

Avoid overly aggressive fluid resuscitation protocols as they increase mortality and complications without improving clinical outcomes. 5, 7

Avoid total parenteral nutrition when enteral feeding is possible as enteral nutrition prevents gut failure and reduces infectious complications. 7

Avoid routine ERCP in all gallstone pancreatitis without cholangitis or obstruction. 5

Avoid prophylactic antibiotics as they do not prevent infection of pancreatic necrosis. 5, 7

Avoid early surgical intervention (<4 weeks) for infected necrosis unless emergency indications are present, as delayed intervention significantly reduces mortality. 5

Monitor for refeeding syndrome in patients with chronic alcoholism and malnutrition—pay particular attention to potassium, magnesium, phosphate, thiamine, and sodium balance. 6

Avoid overfeeding (limit to 25-30 kcal/kg/day, reduce to 15-20 kcal/kg/day in SIRS/MODS or refeeding syndrome risk) as it adversely affects cardiopulmonary and hepatic function. 6