How should acute pancreatitis be managed?

Management of Acute Pancreatitis

Initial Resuscitation and Fluid Management

Begin goal-directed fluid resuscitation immediately upon diagnosis with Lactated Ringer's solution, which reduces systemic inflammatory response syndrome and lowers C-reactive protein levels compared to normal saline. 1

• Administer Lactated Ringer's solution as the preferred crystalloid for initial resuscitation 1
• Avoid aggressive fluid protocols, as they increase mortality and complications without improving outcomes 2
• Monitor circulatory dynamics closely, as large volumes are typically required in severe cases 1
• Provide supplemental oxygen as needed and correct electrolyte and metabolic abnormalities 1

Severity Stratification and Triage

All patients require severity assessment within 48 hours of diagnosis to determine appropriate level of care. 1

• Admit patients with organ failure or systemic inflammatory response syndrome to intensive care or high-dependency units immediately 3, 2
• Manage mild disease (80% of cases) on general medical wards with routine vital sign monitoring including temperature, pulse, blood pressure, and urine output 3, 1
• Use APACHE II scoring with a cutoff of 8 as the preferred multiple factor scoring system 1
• Measure serum C-reactive protein at 48 hours; levels >150 mg/L indicate severe disease 1
• Define severe pancreatitis by persistent organ failure beyond 48 hours, as this most closely predicts mortality 1

Monitoring for Severe Disease

• Establish peripheral intravenous access plus central venous line for continuous CVP monitoring in severe cases 3
• Insert urinary catheter for strict urine output monitoring, targeting >0.5 mL/kg/h 3
• Record pulse, blood pressure, CVP, respiratory rate, oxygen saturation, and temperature hourly 3
• Perform regular arterial blood gas analysis to detect hypoxia or metabolic acidosis early 3
• Use strict asepsis with all invasive monitoring equipment, as these serve as potential sources of subsequent sepsis 1

Nutritional Management

Start oral feeding within 24 hours of presentation as tolerated, rather than keeping the patient nil per os, to reduce the risk of interventions for necrosis by 2.5-fold. 1, 2

• Initiate early enteral nutrition (oral or via nasogastric/nasojejunal tube) to preserve the gut mucosal barrier against bacterial translocation 3, 2
• Use low-fat, normal fat, or solid consistency diets as all have been successful 1
• Provide nasogastric or nasojejunal tube feeding with elemental or semi-elemental formula when oral intake is not feasible—both routes are equally safe 1, 2
• Reserve total parenteral nutrition only for patients unable to tolerate enteral nutrition 1, 2

Antibiotic Strategy

Routine prophylactic antibiotics are NOT indicated in mild pancreatitis or in severe pancreatitis with sterile necrosis. 3, 1

• The American Gastroenterological Association recommends against routine prophylactic antibiotics, as recent high-quality trials show no reduction in infected pancreatic necrosis (OR 0.81) or mortality (OR 0.85) 1, 2
• Reserve antibiotics only for documented infections such as pneumonia, urinary tract infection, cholangitis, line-related sepsis, or infected pancreatic necrosis 3, 1
• If prophylactic antibiotics are used contrary to guideline advice, limit duration to a maximum of 14 days 1, 2
• Consider intravenous cefuroxime as a reasonable balance between efficacy and cost if prophylaxis is chosen 3, 1

Etiological Investigation

Perform abdominal ultrasound immediately to detect gallstones, the leading cause of acute pancreatitis. 3

• Measure baseline serum aminotransferases and bilirubin; early elevation strongly suggests gallstone etiology 3
• If initial ultrasound is negative, repeat ultrasound is the most sensitive next step 3
• Document alcohol intake in units per week, as alcohol accounts for approximately 75% of all cases when combined with gallstones 1
• Conduct comprehensive medication review including oral contraceptives 3
• After the acute phase, measure fasting lipid profile and serum calcium when etiology remains unclear 3

Advanced Imaging for Idiopathic Cases

• The underlying cause should be identified in 75-80% of patients; the proportion classified as "idiopathic" should not exceed 20-25% 3
• Perform endoscopic ultrasound to detect microlithiasis or common bile duct stones 3
• Use magnetic resonance cholangiopancreatography (MRCP) to identify ductal stones or anatomical variants such as pancreas divisum 3
• Consider bile sampling for microlithiasis in recurrent disease 3

Management of Gallstone Pancreatitis

ERCP Indications

Immediate therapeutic ERCP with sphincterotomy is required when cholangitis is present (fever, rigors, positive blood cultures, and deranged liver function tests). 3, 2

• Perform urgent ERCP within 24-72 hours in severe gallstone pancreatitis that fails to improve after 48 hours of intensive resuscitation 3, 2
• All ERCP procedures must be performed under antibiotic coverage 3
• Routine urgent ERCP provides no mortality benefit in acute biliary pancreatitis without cholangitis and should be avoided 2

Timing of Cholecystectomy

For mild gallstone pancreatitis, schedule laparoscopic cholecystectomy within 2-4 weeks, preferably during the same hospital admission. 3, 2

• Same-admission cholecystectomy prevents potentially fatal recurrent attacks 3
• Delaying cholecystectomy beyond 2-4 weeks markedly increases the risk of recurrent biliary events 3
• In severe pancreatitis, postpone cholecystectomy until the inflammatory process has subsided 3

Imaging for Complications

Routine contrast-enhanced CT is NOT indicated in mild pancreatitis unless the patient clinically deteriorates. 3

• In severe disease, perform dynamic contrast-enhanced CT (or MRI) between days 3-10 of admission to evaluate necrosis and fluid collections 3, 2
• Use non-ionic contrast for dynamic CT scanning 2

Management of Pancreatic Necrosis

Patients with persistent symptoms and greater than 30% pancreatic necrosis should undergo image-guided fine needle aspiration. 1, 2

• Perform fine needle aspiration in those with smaller areas of necrosis and clinical suspicion of sepsis 1
• Monitor serial white blood cell count, platelet count, APACHE II score, and CRP >150 mg/L as indicators of potential infection 1
• Sterile necrosis should be managed conservatively with focus on fluid resuscitation, nutritional support, and monitoring for complications 2

Management of Infected Necrosis

Delay interventions for infected necrosis until at least 4 weeks after disease onset when possible, as this results in lower mortality. 2

• Implement a step-up approach, starting with percutaneous or endoscopic drainage and progressing to minimally invasive necrosectomy if no improvement occurs 2
• Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 1, 2
• Transfer patients with extensive necrotizing pancreatitis to specialist centers with expertise in interventional radiology, advanced endoscopy, and pancreatic surgery 2

Emergency Indications for Early Intervention

• Abdominal compartment syndrome unresponsive to conservative management warrants surgical decompression 2
• Acute ongoing bleeding when endovascular approaches have failed requires surgical control 2
• Bowel ischemia or perforation demands immediate surgical intervention 2
• Acute necrotizing cholecystitis occurring during acute pancreatitis requires surgical management 2

Pain Management

• Provide adequate pain control with multimodal approach 1
• Intravenous opiates are generally safe if used judiciously 1
• Consider epidural analgesia for patients requiring high doses of opioids for extended periods 2

Critical Pitfalls to Avoid

• Do not postpone ERCP in patients with cholangitis, as delays increase morbidity and mortality 3
• Do not defer cholecystectomy beyond the 2-4 week window in gallstone pancreatitis; recurrent attacks can be life-threatening 3
• An "idiopathic" label should only be assigned after at least two high-quality ultrasounds and, when necessary, advanced imaging (EUS or MRCP) 3
• Avoid routine prophylactic antibiotics in mild disease or sterile necrosis 3, 1
• Do not keep patients nil per os routinely; early feeding trials should replace prolonged fasting 2
• Avoid aggressive fluid resuscitation protocols, as they increase mortality without improving outcomes 2

Expected Outcomes

• Approximately 80% of acute pancreatitis episodes are mild and can be safely managed on a general ward 3
• The overall mortality from necrotizing pancreatitis is 30-40% 2
• The mortality rate for sterile necrosis is 0-11% 2
• The mortality rate in patients with infected necrosis and organ failure is 35.2% 2