What is the appropriate management of acute pancreatitis?

Management of Acute Pancreatitis

All patients with acute pancreatitis require immediate aggressive fluid resuscitation, oxygen supplementation, pain control, and early enteral nutrition, with severe cases (20% of patients) mandating ICU/HDU admission for full monitoring and systems support. 1

Initial Assessment and Severity Stratification

• Complete severity stratification within 48 hours using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure lasting >48 hours 1
• Recognize that mild acute pancreatitis (80% of cases) has <5% mortality and runs a self-limiting course, while severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 1, 2
• Understand that infected necrosis with organ failure carries 35.2% mortality, sterile necrosis with organ failure has 19.8% mortality, and infected necrosis without organ failure only 1.4% mortality 1
• Treat every patient aggressively until disease severity has been established, as it is difficult to detect patients at risk of complications early in the hospital admission 3

Fluid Resuscitation Strategy

Avoid overly aggressive fluid resuscitation—moderate fluid resuscitation is safer and equally effective. 4 The most recent high-quality RCT (2022) demonstrated that aggressive fluid resuscitation (20 ml/kg bolus followed by 3 ml/kg/hour) resulted in 20.5% fluid overload compared to only 6.3% with moderate resuscitation (10 ml/kg bolus in hypovolemic patients or no bolus in normovolemic patients, followed by 1.5 ml/kg/hour), without any improvement in clinical outcomes 4.

• Target urine output >0.5 ml/kg body weight using crystalloid or colloid as required 3, 1
• Avoid hydroxyethyl starch (HES) fluids as they increase risk of multiple organ failure 1
• Monitor the rate of fluid replacement by frequent measurement of central venous pressure in appropriate patients 3
• Assess hematocrit, blood urea nitrogen, creatinine, and lactate regularly to evaluate adequate tissue perfusion 1

Oxygen Supplementation

• Measure oxygen saturation continuously and administer supplemental oxygen to maintain arterial saturation greater than 95% 3
• Recognize that early oxygen supplementation may be associated with resolution of organ failure, and early resolution of organ failure is associated with very low mortality 3

Monitoring Requirements

For severe acute pancreatitis, establish comprehensive monitoring immediately:

• Place peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 3, 2
• Perform regular hourly assessment of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 3, 1
• Conduct regular arterial blood gas analysis as hypoxia and acidosis may be detected late by clinical means alone 3, 2
• When cardiocirculatory compromise exists or initial resuscitation fails to produce clinical improvement, use a Swan-Ganz catheter for measurement of pulmonary artery wedge pressure, cardiac output, and systemic resistance 3
• Observe strict asepsis in placement and care of invasive monitoring equipment as these may serve as sources of subsequent sepsis in the presence of pancreatic necrosis 3, 1

Pain Management

• Prioritize aggressive pain control as a clinical priority 1, 2
• Use Dilaudid preferentially over morphine or fentanyl in non-intubated patients 1, 2
• Consider epidural analgesia as an alternative or adjunct to intravenous analgesia in a multimodal approach 1, 2
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 1, 2
• Avoid NSAIDs in patients with acute kidney injury 1, 2

Nutritional Support

Initiate early enteral nutrition rather than total parenteral nutrition (TPN) to prevent gut failure and infectious complications. 1, 2

• Start early oral feeding within 24 hours in mild cases as tolerated 1
• Deliver both gastric and jejunal feeding safely—either route is acceptable 1, 2
• Initiate early enteral nutrition even in severe cases 1, 2
• Avoid TPN, but consider partial parenteral nutrition integration if the enteral route is not completely tolerated 1, 2
• Require parenteral nutrition only if ileus persists for more than five days 1, 2

Antibiotic Therapy

Do not administer prophylactic antibiotics routinely in mild acute pancreatitis, as there is no evidence they improve outcomes or reduce septic complications. 1, 5 This represents a major shift from older practices.

• In severe acute pancreatitis with evidence of pancreatic necrosis, the evidence for prophylactic antibiotics remains conflicting—multiple studies show different results with significant heterogeneity 3, 1
• If prophylactic antibiotics are used in severe cases with necrosis, intravenous cefuroxime represents a reasonable balance between efficacy and cost 3, 1
• Administer antibiotics when specific infections occur (chest, urine, bile, or cannula related) 1, 2
• Always perform ERCP under antibiotic cover 3, 1

Important caveat: The Cochrane review highlights that trials used different antibiotics for varying periods with variation in findings between studies, making meta-analysis less reliable 3. The duration of prophylactic treatment remains unclear 3.

Management of Gallstone Pancreatitis

Perform urgent therapeutic ERCP within 72 hours in patients with acute gallstone pancreatitis who have severe disease, cholangitis, jaundice, or dilated common bile duct. 1, 5

• Severe gallstone pancreatitis with increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) requires immediate therapeutic ERCP 3, 1
• Failure of the patient's condition to improve within 48 hours despite intensive initial resuscitation is an indication for urgent ERCP and sphincterotomy 3, 1
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 1, 5
• Perform laparoscopic cholecystectomy during index admission for mild acute gallstone pancreatitis to prevent recurrent pancreatitis 3, 1
• Ideally complete cholecystectomy within two to four weeks in mild gallstone pancreatitis 3, 1
• When ERCP and sphincterotomy are performed during index admission, same-admission cholecystectomy is still advised since there is an increased risk for other biliary complications 3
• In acute gallstone pancreatitis with peripancreatic fluid collections, defer cholecystectomy until fluid collections resolve or stabilize and acute inflammation ceases 3

Imaging Strategy

Obtain dynamic CT scanning with non-ionic contrast within three to 10 days of admission in severe cases to identify pancreatic necrosis and guide management. 3, 1

• Use non-ionic contrast delivered at 3 ml/s using a power injector with a 100 ml bolus 3
• Obtain images through the pancreatic bed using thin collimation (5 mm or less) commencing approximately 40 seconds after the start of injection 3
• Recognize that non-opacification of at least one third of the pancreas, or an area >3 cm diameter, indicates necrosis 3
• Obtain a second series of images beginning at 65 seconds after injection (portal venous phase) for information about patency of main peripancreatic veins 3
• Avoid CT of the pancreas without intravenous contrast enhancement as it gives suboptimal information 3
• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 5

For follow-up imaging:

• Patients with mild pancreatitis or CT severity index of 0-2 require further CT only if there is a change in clinical status suggesting a new complication 3, 1
• In patients with CT severity index of 3-10, additional follow-up scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 3
• Some experts advise a single further scan in patients who make an apparently uncomplicated recovery before hospital discharge to detect asymptomatic complications such as pseudocyst or arterial pseudoaneurysm 3

Management of Infected Necrosis

Consider minimally invasive approaches for debridement of infected necrosis before open surgical necrosectomy. 1, 5

• Recognize that infected necrosis is the most serious local complication with a high mortality rate (40%) 3, 1
• Infected necrosis requires intervention to completely debride all cavities containing necrotic material 1, 5
• Minimally invasive strategies (minimally invasive step-up approach, video-assisted retroperitoneal debridement, or endoscopic approaches) result in less new-onset organ failure but require more interventions compared to open surgery 3
• No differences in mortality have been found between minimally invasive and open approaches 3
• Delaying drainage of infected collections leads to sepsis and increased mortality 1, 5
• Local expertise on different surgical approaches should be taken into account, and a local multidisciplinary group of experts should individualize surgical strategy 3

Specialist Care and Multidisciplinary Approach

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 1, 5

• All cases of severe acute pancreatitis should be managed in an HDU or ITU setting with full monitoring and systems support 3, 1
• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with other complications 1, 5
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 1, 5

Pharmacological Treatment

No specific pharmacological treatment except for organ support and nutrition has proven effective. 1, 2

• Despite initial encouraging results, antiproteases such as gabexate, antisecretory agents such as octreotide, and anti-inflammatory agents such as lexipafant have all proved disappointing in large randomized studies 3, 1

Common Pitfalls to Avoid

• Do not use overly aggressive fluid resuscitation—the 2022 WATERFALL trial definitively showed increased fluid overload without clinical benefit 4
• Do not routinely use prophylactic antibiotics in mild cases—this provides no benefit and contributes to antibiotic resistance 1, 5
• Do not delay drainage of infected collections—this leads to sepsis and increased mortality 1, 5
• Do not perform CT without intravenous contrast—it provides suboptimal information 3
• Do not use total parenteral nutrition when enteral feeding is possible—enteral nutrition prevents gut failure and infectious complications 1, 2
• Do not delay cholecystectomy in mild gallstone pancreatitis—perform during index admission to prevent recurrence 3, 1