What are the essential points to note in the evaluation and management of a patient with suspected acute pancreatitis?

Essential Points in Acute Pancreatitis Management

Diagnosis

Diagnose acute pancreatitis when two of three criteria are present: characteristic epigastric abdominal pain, serum lipase ≥3× upper limit of normal, and/or imaging findings consistent with pancreatitis. 1

• Lipase is preferred over amylase for diagnosis when available, as it remains elevated longer (especially important in alcoholic pancreatitis and delayed presentations) and has better sensitivity 2, 1
• Establish diagnosis within 48 hours of admission 2
• Determine etiology in at least 80% of cases 2
• Obtain initial labs at admission: lipase/amylase, triglycerides, calcium, liver function tests (bilirubin, AST, ALT, alkaline phosphatase) 2
• Perform abdominal ultrasound at admission to identify gallstones or bile duct dilation 2
• Reserve CT scanning for patients with diagnostic uncertainty or clinical deterioration—early CT (within 72 hours) will not show necrosis and does not change initial management 2, 3

Severity Stratification

Stratify severity within 48 hours using clinical impression, obesity, APACHE II score in first 24 hours, CRP >150 mg/L at 48 hours, Glasgow score ≥3, or persisting organ failure after 48 hours. 2, 1

• Persistent organ failure (lasting >48 hours) defines severe pancreatitis and requires ICU admission 2, 1
• Transient organ failure (resolving within 48 hours) should not be considered severe pancreatitis 2
• Patients with predicted severe disease require transfer to HDU/ICU with full monitoring including hourly vital signs, CVP, oxygen saturation, and urine output 1, 4
• Obtain contrast-enhanced CT at 72-96 hours after symptom onset in patients with severe pancreatitis, persistent organ failure, sepsis signs, or clinical deterioration 2, 1

Initial Resuscitation

Provide aggressive intravenous fluid resuscitation immediately to all patients unless cardiovascular or renal comorbidities preclude it, with greatest benefit in the first 12-24 hours. 3, 1

• Establish peripheral IV access at minimum; severe cases require central venous line, urinary catheter, and nasogastric tube 1
• Monitor hematocrit, BUN, creatinine, and lactate as tissue perfusion indicators 1
• Correct electrolyte and metabolic abnormalities 2
• Provide supplemental oxygen as required 2

Pain Management

Use multimodal analgesia: NSAIDs with acetaminophen for mild pain, weak opioids for moderate pain, and consider epidural analgesia for severe pain requiring high-dose opioids. 1

• Intravenous opiates are safe when used judiciously 5
• Always prescribe laxatives when using opioids to prevent constipation 1
• Avoid NSAIDs in patients with acute kidney injury 1

Nutritional Support

Initiate early enteral nutrition within 24 hours if tolerated via nasogastric or nasojejunal route—both are equally effective. 1, 3

• In mild pancreatitis, oral feeding can start immediately if no nausea/vomiting 3
• Enteral nutrition is strongly preferred over parenteral nutrition to prevent infectious complications and gut failure 1, 4
• Reserve parenteral nutrition only for patients who cannot tolerate enteral feeding 1, 3
• Provide nutritional support in patients likely to remain NPO for more than 7 days 2

Antibiotic Management

Do not routinely administer prophylactic antibiotics in mild or severe acute pancreatitis with sterile necrosis. 1, 3

• If prophylactic antibiotics are used, limit to maximum 14 days 2, 1
• Use antibiotics only for documented specific infections: respiratory, urinary, cholangitis, line-related, or confirmed infected necrosis 2, 1
• Cefuroxime or imipenem may be considered in severe pancreatitis if prophylaxis is chosen, but evidence is conflicting 2

Gallstone Pancreatitis Management

Perform urgent ERCP within 24 hours in patients with acute pancreatitis and concurrent cholangitis. 2, 1

• Perform early ERCP (within 72 hours) in patients with high suspicion of persistent common bile duct stone: visible stone on imaging, persistently dilated CBD, or jaundice 2, 6
• All patients with biliary pancreatitis must undergo cholecystectomy during the same admission or within 2-4 weeks after discharge to prevent recurrence 2, 1, 6
• In patients unfit for surgery, ERCP with sphincterotomy alone provides adequate long-term therapy 2

Management of Pancreatic Necrosis

Obtain CT scanning at 6-10 days (not routinely earlier) in patients with persistent organ failure, sepsis signs, or clinical deterioration. 1, 4

• Sterile necrosis does not usually require therapy—manage conservatively with supportive care 2, 4
• Suspect infected necrosis in patients with persistent/worsening symptoms or infection signs after 7-10 days 4
• Patients with >30% necrosis and persistent symptoms, or suspected infected necrosis, require image-guided fine needle aspiration for diagnosis 1, 7
• Delay intervention for infected necrosis until at least 4 weeks when possible to allow wall formation and demarcation, which significantly reduces mortality 4
• Use step-up approach: start with percutaneous or endoscopic drainage, progress to minimally invasive necrosectomy if no improvement 4
• Asymptomatic necrosis or pseudocysts do not warrant intervention regardless of size or location 3

Emergency Indications for Early Intervention

Perform immediate intervention for abdominal compartment syndrome unresponsive to conservative management, acute ongoing bleeding when endovascular approach fails, bowel ischemia, or acute necrotizing cholecystitis. 4

Referral Criteria

Refer patients with extensive necrotizing pancreatitis or complications requiring ICU care, interventional radiology, endoscopy, or surgery to specialist centers. 1, 4

• Every hospital receiving acute admissions should have a designated clinical team for pancreatitis management 1
• Mortality from necrotizing pancreatitis is 30-40% overall, with specialist centers achieving 10-20% 1, 4

Critical Pitfalls to Avoid

• Do not perform daily enzyme measurements—they have no value in assessing clinical progress or prognosis once diagnosis is established 8
• Do not obtain early CT (<72 hours) routinely—it will not show necrosis and does not change initial management 2, 3
• Do not use prophylactic antibiotics routinely—they do not prevent infection of pancreatic necrosis 3, 1
• Do not intervene on sterile necrosis or asymptomatic collections—they resolve spontaneously in >50% of cases 2, 3
• Do not perform early necrosectomy (<4 weeks)—delayed intervention significantly reduces mortality 4