What is the appropriate management of pancreatitis, including fluid resuscitation, pain control, monitoring, imaging, nutritional support, and indications for ERCP, antibiotics, and invasive interventions?

Management of Acute Pancreatitis

Use moderate fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr (after a 10 ml/kg bolus only if hypovolemic), initiate early oral feeding within 24 hours, avoid prophylactic antibiotics, and reserve ERCP for patients with concurrent cholangitis or persistent bile duct obstruction. 1

Fluid Resuscitation Strategy

Aggressive fluid resuscitation increases mortality 2.4-fold in severe acute pancreatitis without improving outcomes—use moderate resuscitation instead. 1

• Administer Lactated Ringer's solution as the preferred crystalloid due to anti-inflammatory effects that reduce systemic inflammation compared to normal saline 1, 2
• Give an initial bolus of 10 ml/kg only in hypovolemic patients; avoid bolus in normovolemic patients to prevent fluid overload 1, 2
• Maintain rate at 1.5 ml/kg/hr for the first 24-48 hours 1, 2
• Keep total crystalloid volume below 4000 ml in the first 24 hours 1, 2
• Avoid rates exceeding 10 ml/kg/hr or 250-500 ml/hr, as these increase complications 2.22-3.25 times without improving outcomes 1
• Target urine output >0.5 ml/kg/hr as a marker of adequate perfusion 1, 2

Common pitfall: Continuing aggressive fluid resuscitation after initial stabilization leads to fluid overload, intra-abdominal hypertension, ARDS, and increased mortality. 1, 3

Severity Assessment and Risk Stratification

Classify severity within 48 hours to guide management intensity: 3

• Mild pancreatitis (80% of cases): <5% mortality, manage on general ward 3
• Moderately severe pancreatitis: requires closer monitoring 4
• Severe pancreatitis (20% of cases): 15% hospital mortality, requires ICU admission 3

Use BISAP score for emergency department risk stratification (score ≥3 predicts severe acute pancreatitis with AUC 0.80-0.81), as it is simple and accurate within the first 24 hours. 1

Alternative scoring systems include APACHE-II (excellent predictive accuracy for severe AP and mortality) and C-reactive protein >150 mg/L at 48 hours (strong predictor of severe disease). 4, 1

Monitoring Based on Severity

Mild Acute Pancreatitis

• Manage on general ward with basic monitoring 1, 3
• Use peripheral intravenous line 1
• Monitor routine vital signs 4
• No routine CT scanning unless clinical deterioration occurs 1, 3

Severe Acute Pancreatitis

• Admit to ICU or high dependency unit with full monitoring 1, 3
• Place central venous line for CVP monitoring, urinary catheter, and nasogastric tube 1, 3
• Monitor hourly: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, temperature, and urine output 1, 3
• Track hematocrit, blood urea nitrogen, creatinine, and lactate as markers of tissue perfusion 4, 3
• Consider Swan-Ganz catheter if cardiocirculatory compromise exists 3
• Use strict aseptic technique for all invasive lines to prevent subsequent sepsis 1

Pain Management

Hydromorphone is preferred over morphine for severe pain in non-intubated patients. 1, 3

• Use a multimodal approach to pain control 1, 3
• Consider epidural analgesia as an alternative or adjunct for moderate to severe pain 3
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 3
• Routinely prescribe laxatives to prevent opioid-induced constipation 1
• Avoid NSAIDs if there is any evidence of acute kidney injury 1, 3

Nutritional Support

Early enteral feeding within 24 hours is safe and beneficial when tolerated—"nothing by mouth" is no longer recommended. 4, 5

Feeding Protocol by Severity

• Mild pancreatitis: Regular oral diet within 24 hours, advance as tolerated 4, 3
• Moderately severe pancreatitis: Enteral nutrition (oral, nasogastric, or nasojejunal); use parenteral nutrition only if enteral not tolerated 4, 3
• Severe pancreatitis: Enteral nutrition (oral, nasogastric, or nasojejunal) within 24-72 hours; parenteral nutrition only if enteral fails 4, 1, 3

Both gastric and jejunal feeding routes are safe in necrotizing pancreatitis—nasojejunal placement is not mandatory. 1, 3

Use a diet rich in carbohydrates and proteins but low in fats when pain has resolved. 1

Rationale: Enteral nutrition prevents gut failure and infectious complications compared to parenteral nutrition, which increases rates of death, multiorgan failure, and systemic infections. 4, 3

Antibiotic Management

Do not administer prophylactic antibiotics—they do not prevent infection of pancreatic necrosis or decrease mortality. 4, 1, 3, 2

Indications for Antibiotics

Use antibiotics only when specific infections are documented: 1, 3, 2

• Infected pancreatic necrosis (confirmed by CT-guided fine-needle aspiration with Gram stain and culture) 4
• Cholangitis 4
• Documented respiratory, urinary, biliary, or catheter-related infections 3, 2
• High risk for intra-abdominal candidiasis 4

Empiric Antibiotic Regimens for Infected Pancreatitis

For immunocompetent patients without MDR colonization: 4

• Meropenem 1 g q6h by extended infusion or continuous infusion
• Doripenem 500 mg q8h by extended infusion
• Imipenem/cilastatin-relebactam 1.25 g q6h by extended infusion

For patients with suspected MDR etiology: 4

• Imipenem/cilastatin-relebactam 1.25 g q6h by extended infusion
• Meropenem/vaborbactam 2 g/2 g q8h by extended infusion
• Ceftazidime/avibactam 2.5 g q8h by extended infusion + Metronidazole 500 mg q8h

Procalcitonin is the most sensitive test for detecting pancreatic infection. 4, 1

Imaging Strategy

Initial Imaging

• Obtain abdominal ultrasonography at admission to look for cholelithiasis or choledocholithiasis 4
• Measure serum lipase or amylase, triglycerides, calcium, and liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) 4

CT Scanning Indications

• Use dynamic CT scanning with non-ionic contrast within 3-10 days of admission for severe cases 1, 3, 2
• CT should be used selectively based on clinical features; routine CT is unnecessary for mild cases unless clinical deterioration occurs 4, 1, 3
• Repeat CT every 2 weeks to track evolution of necrosis or infection in severe cases 3

Management of Biliary Pancreatitis

ERCP is NOT routinely indicated in acute gallstone pancreatitis without complications. 4, 3

Indications for ERCP

• Urgent ERCP (within 24 hours): Patients with concomitant cholangitis 4, 3
• Early ERCP (within 72 hours): High suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated common bile duct, jaundice) 4, 3
• Perform endoscopic sphincterotomy whether or not stones are found at the time of procedure 3

Controversial: Early ERCP in predicted or actual severe gallstone pancreatitis without cholangitis or persistent obstruction—endorsement varies by center and country. 4

Cholecystectomy Timing

Perform same-admission cholecystectomy for biliary pancreatitis if possible, otherwise no later than 2-4 weeks after discharge. 4

This approach reduces recurrent pancreatitis and hospital readmissions. 4

Management of Pancreatic Necrosis and Collections

Sterile necrosis does not usually require therapy. 4

Infected Necrosis Management

• Delay interventions for infected necrosis until at least 4 weeks after disease onset when possible to allow for liquefaction and organization 1, 2
• Surgery is indicated only for infected pancreatic necrosis or pancreatic abscess confirmed by radiologic evidence of gas or fine needle aspirate 1
• Prefer minimally invasive approaches (endoscopic or percutaneous) before open surgical necrosectomy 3
• Complete debridement of all cavities containing necrotic material is required 3

Infected necrosis with organ failure has a mortality rate of 35.2%. 3

Respiratory Support

• Use oxygen therapy to maintain arterial oxygen saturation >95% 3
• Consider high-flow nasal oxygen or continuous positive airway pressure if needed 3
• Institute mechanical ventilation if oxygen supply becomes ineffective in correcting tachypnea and dyspnea 3
• Use lung-protective strategies when invasive ventilation is needed 3

Etiological Investigation and Prevention

Determine the etiology in at least 75% of patients: 4, 3

• Focus history on gallstones, alcohol use, hypertriglyceridemia, hypercalcemia, family history, medications, trauma, and autoimmune diseases 4
• Repeat ultrasound if initially negative for gallstones 4, 3
• Consider endoscopic ultrasound (EUS) for recurrent unexplained pancreatitis 4
• Perform CT or EUS in patients >40 years with unexplained pancreatitis to screen for pancreatic malignancy 4

Alcohol-Induced Pancreatitis

Provide brief alcohol intervention for patients with alcohol-induced pancreatitis—this reduces alcohol consumption and may prevent recurrent episodes. 4

Brief interventions reduce alcohol consumption by a mean difference of 41 g/week compared to control groups. 4

Discontinuing IV Fluids

• Discontinue IV fluids when the patient demonstrates resolution of pain and can tolerate oral intake 1
• Progressively wean IV fluids rather than stopping abruptly to prevent rebound hypoglycemia 1
• In mild pancreatitis, IV fluids are typically discontinued within 24-48 hours 1

Treatments to Avoid

There is no proven benefit for: 3

• Aprotinin
• Glucagon
• Somatostatin
• Fresh frozen plasma
• Peritoneal lavage
• Hydroxyethyl starch (HES) fluids 2