What is the recommended initial and ongoing management for a patient with suspected acute pancreatitis, including fluid resuscitation, pain control, laboratory testing, imaging, cause‑specific treatment, nutrition, and management of complications?

Management of Acute Pancreatitis

All patients with acute pancreatitis require immediate aggressive intravenous fluid resuscitation with isotonic crystalloids (preferably lactated Ringer's solution), adequate pain control with opioids (hydromorphone preferred over morphine in non-intubated patients), and supportive care with close monitoring—while avoiding routine prophylactic antibiotics and reserving imaging for those with unclear diagnosis or clinical deterioration. 1, 2, 3

Initial Assessment and Diagnosis

Diagnostic Criteria

• Diagnosis requires two of three criteria: epigastric abdominal pain, elevated lipase or amylase (≥3 times upper limit of normal), and imaging findings of pancreatic inflammation 4
• Obtain serum amylase or lipase, triglyceride level, calcium level, and liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) at admission to establish diagnosis and determine etiology 1
• Abdominal ultrasonography should be performed at admission to screen for cholelithiasis or choledocholithiasis 1

Severity Assessment

• Assess for organ failure and systemic inflammatory response syndrome (SIRS) immediately upon presentation 3
• Patients with organ failure or SIRS should be admitted to ICU or intermediate care unit 1, 3
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate as markers of adequate tissue perfusion 1
• C-reactive protein level >150 mg/L at 48 hours indicates severe disease 1
• Reserve CT imaging for patients with unclear diagnosis or those failing to improve clinically within 48-72 hours—do not routinely obtain CT at admission 1, 3

Fluid Resuscitation

Fluid Type and Strategy

• Use isotonic crystalloids, with lactated Ringer's solution preferred over normal saline due to potential anti-inflammatory effects and better potassium correction 1, 5
• Early aggressive fluid resuscitation is most beneficial within the first 12-24 hours and may have little benefit beyond this window 3
• Fluid administration should be goal-directed with frequent reassessment to avoid fluid overload, which has detrimental effects 1

Monitoring During Resuscitation

• Monitor vital signs continuously in patients with organ dysfunction 1
• Track hematocrit, BUN, creatinine, and lactate to guide fluid therapy 1, 2
• Target urine output >0.5 mL/kg/hour 6

Pain Control

Analgesic Selection

• Hydromorphone (Dilaudid) is preferred over morphine or fentanyl in non-intubated patients for severe pain 1, 2, 7
• Morphine is acceptable as first-line opioid for severe pain, despite theoretical concerns about sphincter of Oddi spasm 7, 3
• Use opioids on an as-needed basis with close monitoring for mild pancreatitis (80% of cases) 2
• NSAIDs should be avoided in patients with acute kidney injury 1, 7

Advanced Pain Management

• Consider epidural analgesia for patients requiring high opioid doses for extended periods or as adjunct to IV analgesia in multimodal approach 1, 7
• Integrate patient-controlled analgesia (PCA) with any analgesic strategy 1, 7
• Routinely prescribe laxatives to prevent opioid-induced constipation 2, 7
• Use metoclopramide for opioid-related nausea/vomiting 2, 7

Nutritional Support

Feeding Strategy

• In mild pancreatitis, oral feeding can be started immediately if no nausea or vomiting present—the past emphasis on "gut rest" has been revised 2, 3
• For patients likely to remain NPO >7 days, provide enteral nutrition via nasojejunal tube using elemental or semi-elemental formula 1
• Enteral nutrition is preferred over total parenteral nutrition to prevent infectious complications 1, 3
• Use total parenteral nutrition only in those unable to tolerate enteral feeding 1

Antibiotic Use

Prophylaxis Not Recommended

• Routine prophylactic antibiotics are NOT recommended for acute pancreatitis and do not decrease mortality or morbidity 2, 3
• Reserve antibiotics only for confirmed infections: sepsis, infected necrosis, cholangitis, or pancreatic abscess 2, 6
• Procalcitonin is the most sensitive test for detecting pancreatic infection—use to guide antibiotic decisions 2
• Fungal prophylaxis is not recommended despite increased risk with extensive necrosis 1

When Infection Confirmed

• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention and decrease morbidity 3

Etiology-Specific Management

Gallstone Pancreatitis

• Urgent ERCP (within 24 hours) is mandatory for patients with concomitant cholangitis 1, 3
• Early ERCP (within 72 hours) should be performed for high suspicion of persistent common bile duct stone: visible stone on imaging, persistently dilated CBD, or jaundice 1
• Early ERCP in severe gallstone pancreatitis without cholangitis or suspected persistent stone remains controversial 1
• Perform cholecystectomy during same hospital admission if possible, otherwise within 2-4 weeks after discharge for patients fit for surgery 1
• In patients unfit for surgery, ERCP with sphincterotomy alone provides adequate long-term therapy 1

Unexplained Pancreatitis

• Perform CT or endoscopic ultrasound (EUS) in patients >40 years old to screen for underlying pancreatic malignancy 1
• Extensive evaluation not recommended for single episode in patients <40 years 1
• For recurrent episodes, consider EUS and/or ERCP, with EUS preferred as initial test 1

Management of Complications

Pancreatic Necrosis

• Sterile necrosis does not require intervention—recognize that necrosis evolves and liquefies over time into organized "walled-off" necrosis 1
• Peripancreatic fluid on CT (occurs in 30-50% of severe cases) resolves spontaneously in more than half of cases 2
• For infected necrosis, delay surgical/radiologic/endoscopic drainage preferably for 4 weeks to allow wall formation around necrosis 1, 3
• Surgery is not indicated for sterile pancreatitis 2

Monitoring for Deterioration

• Daily reassessment for complications including clinical, biochemical, and radiological evaluation is necessary 2
• Continuous vital signs monitoring including oxygen saturation is mandatory for severe cases 2
• Regular arterial blood gas analysis to detect hypoxia and acidosis early 2

Disposition and Monitoring

ICU Admission Criteria

• Persistent organ dysfunction despite adequate fluid resuscitation requiring specific organ support 1
• All patients with severe acute pancreatitis (20% of cases, 95% of deaths) require intensive monitoring in HDU/ICU 2, 7

General Ward Management

• Mild pancreatitis (80% of cases) can be managed on general wards with close monitoring 2
• Continue fundamental medical treatment until clinical symptoms subside with normal laboratory data 8