What is the appropriate management of acute pancreatitis?

Management of Acute Pancreatitis

All patients with severe acute pancreatitis must be managed in an intensive care unit (ICU) or high-dependency unit (HDU) with full monitoring and organ support, while mild cases can be managed on general wards with early oral feeding and supportive care. 1, 2

Initial Assessment and Severity Stratification

• Complete severity stratification within 48 hours of presentation using clinical impression, APACHE II score, C-reactive protein, Glasgow score, or persistent organ failure lasting more than 48 hours 1, 3
• Mild acute pancreatitis (80% of cases) has less than 5% mortality and follows a self-limiting course 2, 3
• Severe acute pancreatitis (20% of cases) accounts for 95% of deaths with approximately 15% hospital mortality 2, 3
• Infected necrosis with organ failure carries 35.2% mortality, sterile necrosis with organ failure has 19.8% mortality, and infected necrosis without organ failure has only 1.4% mortality 1, 2

Fluid Resuscitation

Use lactated Ringer's solution rather than normal saline as the primary resuscitation fluid. 4

• Lactated Ringer's solution reduces the risk of moderate-to-severe acute pancreatitis by 31%, mortality by 62%, and decreases systemic and local complications compared to normal saline 4
• Target urine output greater than 0.5 mL/kg/hour to ensure adequate renal perfusion 1, 2
• Avoid hydroxyethyl starch (HES) fluids as they increase the risk of multiple organ failure 2, 3
• Monitor fluid replacement intensity by frequent central venous pressure measurements in selected patients 1

Oxygen Therapy and Monitoring

• Continuously monitor arterial oxygen saturation and provide supplemental oxygen to maintain saturation at or above 95% 1
• Perform hourly checks of pulse, blood pressure, central venous pressure, respiratory rate, oxygen saturation, urine output, and temperature in severe cases 1, 3
• Obtain regular arterial blood gases because hypoxia and acidosis may not be clinically evident until late 1, 2
• Monitor hematocrit, blood urea nitrogen, creatinine, and lactate to assess adequate tissue perfusion 1, 2

Pain Management

Use Dilaudid as the preferred opioid over morphine or fentanyl in non-intubated patients. 1, 2

• Pain control is a clinical priority requiring aggressive management 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 oral feeding within 24 hours in mild acute pancreatitis as tolerated. 1, 2

• In patients unable to feed orally, use enteral nutrition rather than total parenteral nutrition to prevent gut failure and infectious complications 1, 2
• Both nasogastric and nasojejunal routes are acceptable and equally effective for enteral nutrition 5, 1
• The nasogastric route for feeding can be used as it appears effective in 80% of cases 5
• If ileus persists for more than five days, parenteral nutrition will be required 1, 2
• Early enteral nutrition should be initiated even in severe cases 1

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, 2, 3

• In severe acute pancreatitis with confirmed necrosis, the benefit of prophylactic antibiotics remains uncertain with heterogeneous study results 1
• If prophylactic antibiotics are chosen for necrotizing disease, intravenous cefuroxime offers a reasonable balance of efficacy and cost 1, 2
• Antibiotics must be administered when a documented infection is present (respiratory, urinary, biliary, or catheter-related) 1, 2
• ERCP should always be performed under antibiotic cover 1, 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 a dilated common bile duct. 5, 1, 2

• Patients with signs of cholangitis require endoscopic sphincterotomy or duct drainage by stenting to ensure relief of biliary obstruction 5
• All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found in the bile duct 5, 1
• Perform laparoscopic cholecystectomy during the index admission for mild gallstone pancreatitis to prevent recurrence 1, 2
• In mild disease, definitive cholecystectomy is ideally completed within 2–4 weeks of presentation 1
• If peripancreatic fluid collections are present, defer cholecystectomy until the collections have resolved or stabilized and acute inflammation has subsided 1

Imaging Strategy

Obtain contrast-enhanced dynamic CT scan between days 3 and 10 of admission in severe pancreatitis to detect necrosis and guide further management. 1

• Use non-ionic iodinated contrast injected at 3 mL/second with a 100 mL bolus 1
• Acquire thin-slice (≤5 mm) images of the pancreatic region beginning approximately 40 seconds after contrast start (arterial phase) 1
• Perform a second acquisition at approximately 65 seconds (portal venous phase) to evaluate the patency of major peripancreatic veins 1
• Non-opacification of one-third or more of the pancreas or a non-enhancing area greater than 3 cm indicates necrosis 1
• CT without intravenous contrast is discouraged because it yields suboptimal diagnostic information 1
• Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1, 2
• Patients with a CT severity index 0–2 (mild disease) need repeat CT only if clinical deterioration suggests a new complication 1
• Patients with a CT severity index 3–10 (moderate-to-severe disease) require repeat imaging only when clinical status worsens or fails to improve 1

Management of Infected Necrosis

Consider minimally invasive step-up approaches (percutaneous drainage, video-assisted retroperitoneal debridement, or endoscopic transluminal necrosectomy) before open surgical necrosectomy. 1

• Infected pancreatic necrosis carries a high mortality of approximately 40% 1, 2
• All patients with persistent symptoms and greater than 30% pancreatic necrosis, and those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration 7–14 days after onset to obtain cultures 5, 1
• Minimally invasive step-up approaches reduce the incidence of new-onset organ failure compared with open necrosectomy, although they may require more procedural sessions 1
• Overall mortality does not differ significantly between minimally invasive and open surgical necrosectomy 1
• Patients with infected necrosis will require intervention to completely debride all cavities containing necrotic material 5, 1

Specialist Care and Multidisciplinary Management

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis. 5, 2, 3

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (greater than 30% necrosis) or with other complications who may require ICU care, or interventional radiological, endoscopic, or surgical procedures 5, 1
• A multidisciplinary team involving intensivists, surgeons, gastroenterologists, and radiologists is essential 1, 2

Pharmacological Therapy

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

• Antiprotease (gabexate), antisecretory (octreotide), and anti-inflammatory (lexipafant) agents have failed to demonstrate benefit in large randomized trials and are not recommended 1

Common Pitfalls to Avoid

• Do not delay drainage of infected collections as this leads to sepsis and increased mortality 3
• Do not use prophylactic antibiotics routinely in mild cases as they provide no benefit 1, 2, 3
• Do not use normal saline when lactated Ringer's solution is available, as it is associated with worse outcomes 4
• Do not perform CT without intravenous contrast when evaluating for necrosis, as it provides inadequate diagnostic information 1
• Maintain strict aseptic technique for all invasive monitoring devices to prevent catheter-related sepsis, especially in the presence of pancreatic necrosis 1