Management of Acute Pancreatitis
Fluid Resuscitation
Use moderate (non-aggressive) goal-directed fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr following an initial bolus of 10 ml/kg only in hypovolemic patients, keeping total crystalloid administration below 4000 ml in the first 24 hours. 1, 2, 3
Initial Bolus Strategy
- Administer 10 ml/kg bolus over 2 hours only if the patient is hypovolemic (tachycardia, hypotension, poor skin turgor, oliguria) 1, 3
- Give no bolus if the patient is normovolemic 1, 3
- Lactated Ringer's solution is strongly preferred over normal saline due to anti-inflammatory effects and reduction in systemic inflammation 1, 2, 3
Maintenance Fluid Rate
- Continue at 1.5 ml/kg/hr for the first 24-48 hours 1, 2, 3
- Never exceed 10 ml/kg/hr or 250-500 ml/hr, as aggressive fluid resuscitation increases mortality 2.45-fold in severe acute pancreatitis (RR: 2.45,95% CI: 1.37-4.40) without improving outcomes 1, 2
- Keep total crystalloid volume below 4000 ml in the first 24 hours to prevent fluid overload complications 1, 3
Monitoring Targets During Resuscitation
- Urine output >0.5 ml/kg/hr as the primary bedside marker of adequate perfusion 1, 3
- Oxygen saturation ≥95% with supplemental oxygen as needed 1, 3
- Heart rate, mean arterial pressure, and blood pressure to guide ongoing fluid administration 1, 3
- Serial hematocrit, blood urea nitrogen, creatinine, and lactate levels as markers of tissue perfusion 4, 1, 2
- If hematocrit does not decline within 24 hours, this signals insufficient resuscitation and heightened risk of pancreatic necrosis 1
Critical Pitfall: Fluid Overload
- If lactate remains elevated after 4L of fluid, do not continue aggressive fluid resuscitation—instead, perform hemodynamic assessment to determine the type of shock 2, 3
- Monitor continuously for fluid overload, which increases mortality, worsens ARDS, and increases complications 2.22-3.25 times 1, 2
- Avoid hydroxyethyl starch (HES) fluids entirely due to increased multiple organ failure without mortality benefit 1
Severity Assessment and Risk Stratification
Classify patients into mild, moderately severe, or severe acute pancreatitis within the first 24 hours using BISAP score (preferred for emergency department use) or APACHE-II score, as this determines monitoring intensity and disposition. 2
Severity Classification
- Mild acute pancreatitis (80% of cases): No organ failure, no local or systemic complications 4
- Moderately severe acute pancreatitis: Transient organ failure (<48 hours) and/or local complications 4, 2
- Severe acute pancreatitis (20% of cases): Persistent organ failure (>48 hours), accounts for 95% of deaths 4, 2
Prognostic Markers
- Hematocrit >44% independently predicts pancreatic necrosis and requires prompt intervention 1
- C-reactive protein ≥150 mg/L on day 3 indicates severe disease 1
- Blood urea nitrogen >20 mg/dL suggests inadequate resuscitation or severe disease 1
- Procalcitonin is the most sensitive laboratory test for detecting pancreatic infection; low values are strong negative predictors of infected necrosis 4, 2
- BISAP score ≥3 predicts severe acute pancreatitis with AUC 0.80-0.81 within the first 24 hours 2
Initial Laboratory Workup
- Serum lipase and/or amylase (at least 3 times upper limit of normal for diagnosis) 2, 5
- Complete blood count with hematocrit 4, 1, 2
- Comprehensive metabolic panel including BUN, creatinine, calcium 2, 5
- Liver function tests (bilirubin, AST, ALT, alkaline phosphatase) to assess for biliary etiology 2
- Triglycerides to rule out hypertriglyceridemia 2, 5
Severity-Based Management Approach
Mild Acute Pancreatitis (General Ward)
- Routine vital signs monitoring (temperature, pulse, blood pressure, urine output) on a general ward 4, 2
- Peripheral intravenous line for fluids; urinary catheter rarely needed 4, 3
- Regular oral diet within 24 hours and advance as tolerated 4, 1, 2
- Oral pain medications (avoid NSAIDs if any evidence of acute kidney injury) 2
- No routine CT scanning unless clinical deterioration occurs 4, 2
- Discontinue IV fluids within 24-48 hours when pain resolves and oral intake is tolerated 2, 3
Moderately Severe Acute Pancreatitis (Step-Down Unit)
- Enteral nutrition (oral, nasogastric, or nasojejunal); reserve parenteral nutrition only if enteral feeding not tolerated 4, 2
- IV pain medications with multimodal approach; hydromorphone preferred over morphine 2
- IV fluids to maintain hydration at 1.5 ml/kg/hr 4, 1
- Monitor hematocrit, BUN, creatinine serially 4, 2
- Continuous vital signs monitoring 4, 2
Severe Acute Pancreatitis (ICU/HDU)
- ICU or high dependency unit admission with full monitoring 4, 2
- Central venous line for CVP monitoring and fluid administration 4, 3
- Urinary catheter for strict intake/output monitoring 4, 3
- Nasogastric tube for gastric decompression 4, 3
- Swan-Ganz catheter if cardiocirculatory compromise exists or initial resuscitation fails 4
- Early enteral nutrition within 24-72 hours (oral, nasogastric, or nasojejunal); use parenteral nutrition only if enteral feeding fails 4, 2
- Mechanical ventilation if respiratory failure develops 4
- Strict asepsis in placement and care of all invasive monitoring equipment to prevent subsequent sepsis 4, 3
Pain Management
Use IV opioids with a multimodal approach, preferring hydromorphone over morphine for severe pain in non-intubated patients, and routinely prescribe laxatives to prevent opioid-induced constipation. 2
- Hydromorphone is preferred over morphine for severe pain 2
- Multimodal pain control approach to minimize opioid requirements 2
- Avoid NSAIDs if any evidence of acute kidney injury 2
- Routine prescription of laxatives to prevent opioid-induced constipation 2
- Oral pain medications sufficient for mild acute pancreatitis 4, 2
Nutritional Support
Begin early oral feeding within 24 hours as tolerated rather than keeping the patient nil per os; if oral feeding is not tolerated, use enteral nutrition (nasogastric or nasojejunal) rather than parenteral nutrition. 1, 2
Mild Acute Pancreatitis
- Regular oral diet within 24 hours and advance as tolerated 4, 1, 2
- Diet rich in carbohydrates and proteins but low in fats when pain has resolved 2
Moderately Severe and Severe Acute Pancreatitis
- Enteral nutrition (oral, nasogastric, or nasojejunal) within 24-72 hours 4, 2
- Both gastric and jejunal feeding routes are safe in necrotizing pancreatitis 2
- Reserve parenteral nutrition only if enteral feeding is not tolerated 4, 2
- Enteral nutrition is associated with lower rates of death, multiorgan failure, local complications, and systemic infections compared to parenteral nutrition 5
Transitioning Off IV Fluids
- Discontinue IV fluids when pain resolves, patient tolerates oral intake, and hemodynamic stability is maintained 2, 3
- Progressively wean IV fluids rather than stopping abruptly to prevent rebound hypoglycemia 2, 3
Antibiotic Use
Do not administer prophylactic antibiotics in acute pancreatitis, as they do not prevent infection of pancreatic necrosis or reduce mortality; use antibiotics only when specific infections are documented. 4, 2
When NOT to Use Antibiotics
- No routine prophylactic antibiotics for mild, moderately severe, or severe acute pancreatitis 4, 2
- Prophylactic antibiotics are not associated with significant decrease in mortality or morbidity 4
When to Use Antibiotics
- Infected pancreatic necrosis confirmed by CT-guided fine-needle aspiration (FNA) for Gram stain and culture 4, 2
- Cholangitis requiring urgent ERCP 2
- Documented infections: respiratory, urinary, biliary, or catheter-related 4, 2
- Procalcitonin is the most sensitive test for detecting pancreatic infection 4, 2
Empiric Antibiotic Regimens for Infected Pancreatitis
For immunocompetent patients without MDR colonization:
- Meropenem 1 g every 6 hours by extended infusion or continuous infusion 4, 2
- OR Doripenem 500 mg every 8 hours by extended infusion 4, 2
- OR Imipenem/cilastatin 500 mg every 6 hours by extended infusion 4
For suspected MDR pathogens (based on epidemiological data, gut colonization, or specific risk factors):
- Imipenem/cilastatin-relebactam 1.25 g every 6 hours by extended infusion 4, 2
- OR Meropenem/vaborbactam 2 g/2 g every 8 hours by extended infusion or continuous infusion 4, 2
- OR Ceftazidime/avibactam 2.5 g every 8 hours by extended infusion + Metronidazole 500 mg every 8 hours 4, 2
For documented beta-lactam allergy:
- Eravacycline 1 mg/kg every 12 hours 4
Imaging Strategy
Perform abdominal ultrasonography at admission to evaluate for gallstones; reserve contrast-enhanced CT for patients with clinical deterioration, suspected complications, or when severity assessment is needed after 3-10 days. 4, 2, 6
Initial Imaging
- Abdominal ultrasound at admission to evaluate for gallstones or common bile duct stones 2
- No routine CT scanning in mild disease unless clinical deterioration occurs 4, 2
When to Perform CT Scanning
- Clinical deterioration or signs of complications 4, 2
- Contrast-enhanced CT within 3-10 days for severe cases to assess for necrosis and predict prognosis 2, 6, 5
- CT-guided fine-needle aspiration (FNA) for Gram stain and culture if infected necrosis is suspected 4, 2
Additional Imaging Modalities
- MRI or endoscopic ultrasound (EUS) for idiopathic pancreatitis to exclude pancreatic tumors or detect common bile duct stones 4
- MRI cholangiography under evaluation for biliary etiology 4
Etiology-Specific Therapy
Identify the underlying cause in at least 75% of patients; perform urgent ERCP within 24 hours for cholangitis, and early ERCP within 72 hours for persistent common bile duct stones. 4, 2
Biliary Pancreatitis
- Urgent ERCP within 24 hours for patients with concomitant cholangitis 2
- Early ERCP within 72 hours for high suspicion of persistent common bile duct stones (visible stone on imaging, persistent ductal dilation, or jaundice) 2
- ERCP is NOT routinely indicated in acute gallstone pancreatitis without complications 2
- Cholecystectomy during index admission when feasible; if not, complete within 2-4 weeks after discharge to reduce recurrent pancreatitis episodes and hospital readmissions 2
Alcohol-Related Pancreatitis
- Brief alcohol-intervention programs lower subsequent alcohol intake by an average of 41 g per week 2
Idiopathic Pancreatitis
- No more than 20-25% should be classified as idiopathic 4
- CT scan (particularly in elderly) to exclude pancreatic tumor 4
- Endoscopic ultrasound to detect common bile duct stones 4
- Bile sampling for microlithiasis in patients with repeated attacks 4
Indications for Invasive Necrosis Treatment
Delay interventions for infected necrosis until at least 4 weeks after disease onset when possible; surgery is indicated only for infected pancreatic necrosis or pancreatic abscess confirmed by radiologic evidence of gas or fine needle aspirate. 2, 6
When to Intervene
- Infected pancreatic necrosis confirmed by CT-guided FNA showing bacteria on Gram stain or culture 4, 2, 6
- Pancreatic abscess confirmed by radiologic evidence of gas or FNA 6
- Clinical deterioration despite maximal medical therapy 6
Timing of Intervention
- Delay necrosectomy until at least 4 weeks after disease onset when possible to allow demarcation of necrosis 2, 6
- Non-surgical treatment with antibiotics is preferred if general condition is stable 6
Approach Options
- Percutaneous drainage 6
- Endoscopic drainage 6
- Laparoscopic necrosectomy 6
- Open surgical necrosectomy (perform as late as possible) 6
Sterile Necrosis
- Non-surgical treatment should be indicated for patients with sterile pancreatitis 6
Treatments Without Proven Benefit
Do not use aprotinin, somatostatin, glucagon, fresh frozen plasma, or peritoneal lavage, as none have demonstrated clinical benefit in acute pancreatitis. 4, 2