Treatment of Acute Pancreatitis
For acute pancreatitis presenting with left upper quadrant pain and nausea, initiate aggressive IV fluid resuscitation with Lactated Ringer's solution targeting urine output >0.5 ml/kg/hr, provide hydromorphone for pain control, keep the patient NPO initially in mild cases but advance to oral feeding as soon as nausea resolves, and admit severe cases to ICU with continuous monitoring. 1, 2
Initial Assessment and Severity Stratification
Immediately classify the patient as mild or severe upon diagnosis, as this determines the entire treatment pathway—severe disease carries 95% of mortality and requires ICU-level care, while mild disease has <5% mortality and needs only general ward supportive measures. 2
Use these criteria to predict severity:
- Clinical impression and obesity 2
- APACHE II score in first 24 hours 2
- C-reactive protein >150 mg/L 2
- Glasgow score ≥3 2
- Persisting organ failure after 48 hours 2
Diagnostic confirmation requires serum amylase activity four times above normal or lipase greater than twice the upper limit of normal in the appropriate clinical setting. 3 Lipase remains elevated longer and has higher specificity than amylase. 3
Fluid Resuscitation
Administer goal-directed moderate fluid resuscitation with Lactated Ringer's solution rather than aggressive fluid resuscitation, targeting urine output >0.5 ml/kg body weight. 2 Early aggressive intravenous hydration is most beneficial within the first 12-24 hours and may have little benefit beyond this window. 4
All patients require immediate hemodynamic assessment with resuscitative measures begun as needed. 4
Pain Management
Use hydromorphone (Dilaudid) as the preferred opioid in non-intubated patients for severe pain, with morphine as an acceptable alternative. 1, 5, 2 The World Society of Emergency Surgery emphasizes that no restrictions on pain medication are warranted—adequate pain control is the clinical priority. 5
- For mild pain: NSAIDs with or without acetaminophen 5
- For moderate pain: weak opioids (codeine or tramadol) combined with non-opioid analgesics 5
- For severe pain: hydromorphone or morphine 1, 5
Routinely prescribe laxatives to prevent opioid-induced constipation and use metoclopramide for opioid-related nausea/vomiting. 1, 5 Consider epidural analgesia as an adjunct for patients requiring high opioid doses for extended periods. 5, 2
Nutritional Management
In mild pancreatitis, initiate oral feeding immediately once pain and nausea resolve—do not keep patients NPO unnecessarily. 2, 6 The past clinical emphasis on "gut rest" to decrease pancreatic stimulation has been revised. 1
In severe cases requiring nutritional support, attempt enteral nutrition first via nasogastric tube (effective in 80% of cases) or nasoenteral tube if oral feeding is not tolerated. 3, 2 Enteral nutrition should be commenced 48 hours after presentation in severe pancreatitis. 6 Total parenteral nutrition should be avoided where possible. 6
Monitoring Requirements
For mild acute pancreatitis (80% of cases): opioids on an as-needed basis with close monitoring on general wards suffice. 1
For severe acute pancreatitis (20% of cases, 95% of deaths): intensive monitoring in HDU/ITU settings is mandatory. 1, 2 Monitor hourly:
- Pulse, blood pressure, CVP 2
- Respiratory rate and oxygen saturation 1, 2
- Urine output and temperature 2
- Regular arterial blood gas analysis to detect hypoxia and acidosis early 1
Daily reassessment for development of complications including clinical, biochemical, and radiological evaluation is necessary. 1 Patients with organ failure persisting >48 hours during the first week are at greatest risk of death. 2
Antibiotic Strategy
Do not use prophylactic antibiotics in mild pancreatitis or biliary pancreatitis—there is no evidence of benefit. 2, 4 Prophylactic antibiotics do not decrease mortality or morbidity. 1
Reserve antibiotics only for treating confirmed infected severe acute pancreatitis, not prophylaxis. 1 Procalcitonin is the most sensitive test for detecting pancreatic infection. 1 Consider prophylactic antibiotics only in severe acute pancreatitis with evidence of pancreatic necrosis >30%. 2
Imaging Strategy
Routine CT scanning is unnecessary in mild cases unless clinical deterioration occurs. 2 Chest and abdominal plain x-rays should be performed routinely to provide a baseline and exclude other pathology such as perforated viscus. 3
Perform dynamic contrast-enhanced CT with non-ionic contrast within 3-10 days of admission for severe cases to identify pancreatic necrosis. 2 Peripancreatic fluid on CT occurs in 30-50% of severe cases and resolves spontaneously in more than half. 1
Management of Gallstone Pancreatitis
Perform urgent therapeutic ERCP within 72 hours in patients with severe gallstone pancreatitis, cholangitis, jaundice, or dilated common bile duct. 3, 2 All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct. 3, 2
After an attack of mild acute pancreatitis, patients with gallstones should undergo cholecystectomy during the same admission or within two weeks after discharge to prevent recurrence. 3 There is a significant risk of further acute pancreatitis which may be severe and life-threatening. 3
Management of Pancreatic Necrosis
Surgical intervention should be limited to patients with infected pancreatic necrosis or pancreatic abscess confirmed by radiologic evidence of gas or fine needle aspirate results. 1 Surgery is not indicated for sterile acute pancreatitis. 1
Operative necrosectomy and/or drainage should be delayed at least 2-3 weeks to allow for demarcation of necrotic tissue. 1, 2 Perform image-guided fine needle aspiration 7-14 days after onset for patients with persistent symptoms and >30% pancreatic necrosis. 2 Infected necrosis carries 40% mortality. 2
Mortality Benchmarks
Overall mortality should be lower than 10%, and less than 30% in those diagnosed with severe disease. 3 Centers have reported improved outcomes following aggressive surgical debridement for infected necrosis, with mortality rates between 10-20%. 3