What is the recommended treatment for acute pancreatitis—including aggressive fluid resuscitation, nil by mouth, analgesia, monitoring, early low‑fat enteral nutrition, management of gallstone, alcohol‑related, and hypertriglyceridemia‑induced causes, appropriate use of antibiotics, and care for severe disease—and for chronic pancreatitis, including pain control, pancreatic enzyme replacement, dietary measures, and adjunctive therapies?

Treatment of Acute Pancreatitis

For acute pancreatitis, initiate moderate fluid resuscitation with Lactated Ringer's solution at 1.5 ml/kg/hr (after a 10 ml/kg bolus only if hypovolemic), start a regular oral diet within 24 hours for mild disease, avoid prophylactic antibiotics entirely, and provide multimodal analgesia with hydromorphone preferred over morphine. 1

Initial Fluid Resuscitation Strategy

Moderate (non-aggressive) fluid resuscitation is critical because aggressive protocols increase mortality 2.45-fold in severe acute pancreatitis without improving outcomes. 1

• Administer a 10 ml/kg bolus of Lactated Ringer's solution only if the patient is hypovolemic; give no bolus if normovolemic 1
• Maintain 1.5 ml/kg/hr for the first 24–48 hours 1
• Keep total crystalloid volume below 4000 ml in the first 24 hours 1
• Lactated Ringer's solution is superior to normal saline, reducing systemic inflammatory response syndrome (SIRS) at 24 hours by 84% versus 0%, and lowering C-reactive protein levels (51.5 vs 104 mg/dL) 2
• Avoid hydroxyethyl starch (HES) fluids entirely because they increase multiple organ failure risk (odds ratio ≈3.9) without mortality benefit 3, 4

Monitoring Targets During Resuscitation

• Maintain urine output >0.5 ml/kg/hr as the principal bedside marker of adequate perfusion 5, 1
• Maintain oxygen saturation >95% with supplemental oxygen 5, 1
• Monitor central venous pressure in appropriate patients to guide fluid replacement rate 5
• Serially measure hematocrit, blood urea nitrogen, creatinine, and lactate as markers of tissue perfusion 5, 1
• If lactate remains elevated after 4L of fluid, do not continue aggressive resuscitation; perform hemodynamic assessment to determine the type of shock 1

Severity-Based Management Algorithm

Mild Acute Pancreatitis (80% of cases, <5% mortality) 4

• Manage on a general medical ward with routine vital-sign monitoring 1
• Insert a peripheral intravenous line; urinary catheterization is rarely required 1
• Initiate a regular oral diet within 24 hours of presentation and advance as tolerated 1
• Avoid routine contrast-enhanced CT; reserve imaging for clinical deterioration 1
• Discontinue intravenous fluids within 24–48 hours once pain resolves and oral intake is adequate 1
• Use oral analgesics as needed 4

Moderately Severe Acute Pancreatitis 1

• Provide closer clinical monitoring, ideally in a step-down unit 1
• Provide enteral nutrition (oral, nasogastric, or nasojejunal) as first-line feeding strategy 1
• Reserve parenteral nutrition only when enteral feeding is not tolerated 1
• Maintain intravenous crystalloid at 1.5 ml/kg/hr during the first 24–48 hours 1
• Use intravenous analgesics for pain control 4

Severe Acute Pancreatitis (20% of cases, 15% hospital mortality) 4

• Admit to intensive-care or high-dependency unit with full physiologic monitoring 1, 4
• Place a central venous catheter for CVP monitoring and fluid administration 1, 4
• Insert a urinary catheter for strict input-output balance 1, 4
• Use a nasogastric tube for gastric decompression when indicated 1, 4
• Consider a Swan-Ganz catheter if cardiocirculatory compromise persists despite initial resuscitation 1, 4
• Initiate early enteral nutrition within 24–72 hours (oral, nasogastric, or nasojejunal) 1
• Reserve parenteral nutrition for failure of enteral feeding 1
• Provide mechanical ventilation for respiratory failure 4
• Apply strict aseptic technique for all invasive monitoring devices to minimize secondary sepsis 1, 4

Nutritional Support

Early enteral nutrition is strongly preferred over parenteral nutrition to prevent gut failure and infectious complications. 4

• Mild pancreatitis: Regular oral diet within 24 hours, advance as tolerated 1
• Moderately severe pancreatitis: Enteral nutrition (oral, nasogastric, or nasojejunal); parenteral nutrition only if enteral not tolerated 1
• Severe pancreatitis: Start enteral nutrition within 24–72 hours; use parenteral nutrition only if enteral feeding fails 1
• Both nasogastric and nasojejunal feeding routes are equally safe in necrotizing pancreatitis 4
• When oral refeeding begins, use a diet rich in carbohydrates and proteins but low in fats 5

Antibiotic Management

Prophylactic antibiotics do not prevent infection of pancreatic necrosis nor reduce mortality and should not be administered routinely. 1, 5, 4

When to Use Antibiotics

Antibiotics should be given only for documented infections: 1

• Infected pancreatic necrosis confirmed by CT-guided fine-needle aspiration with positive Gram stain or culture 1
• Cholangitis requiring urgent ERCP 1
• Pneumonia, urinary tract infection, or catheter-related sepsis 1, 4

Empiric Antibiotic Regimens (When Infection Documented)

For immunocompetent patients without multidrug-resistant (MDR) colonization: 1

• Meropenem 1 g every 6 hours (extended or continuous infusion) 1
• or Doripenem 500 mg every 8 hours (extended infusion) 1
• or Imipenem/cilastatin-relebactam 1.25 g every 6 hours (extended infusion) 1

For suspected MDR pathogens: 1

• Imipenem/cilastatin-relebactam 1.25 g every 6 hours (extended infusion) 1
• or Meropenem/vaborbactam 2 g/2 g every 8 hours (extended infusion) 1
• or Ceftazidime/avibactam 2.5 g every 8 hours (extended infusion) + Metronidazole 500 mg every 8 hours 1

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

Pain Management

Use a multimodal approach to pain control, with hydromorphone (Dilaudid) preferred over morphine or fentanyl in non-intubated patients. 4

• Hydromorphone is preferred over morphine for severe pain 1
• Consider epidural analgesia as an alternative or adjunct for moderate to severe pain 4
• Integrate patient-controlled analgesia (PCA) with every pain management strategy 4
• Routinely prescribe laxatives to prevent opioid-induced constipation 1
• Avoid NSAIDs if there is any evidence of acute kidney injury 1

Imaging Strategy

• Perform abdominal ultrasonography at admission to evaluate for gallstones or common bile duct stones 1
• Obtain baseline serum lipase/amylase, triglycerides, calcium, and liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) on presentation 1
• Contrast-enhanced CT scanning should be used selectively based on clinical deterioration; routine CT is not required for mild disease 1
• For severe cases, perform dynamic CT scanning with non-ionic contrast within 3–10 days of admission 1, 4
• Use CT-guided fine-needle aspiration for microbiologic confirmation when infected necrosis is suspected 4

Biliary Pancreatitis Management

ERCP is not routinely indicated in acute gallstone pancreatitis without complications. 1

• Urgent ERCP (within 24 hours) is recommended for patients with concomitant cholangitis 1
• Early ERCP (within 72 hours) is advised when there is high suspicion of persistent common bile duct stones (visible stone on imaging, persistent ductal dilation, or jaundice) 1
• Cholecystectomy should be performed during the index admission when feasible; if not, complete within 2–4 weeks after discharge 1
• Timely cholecystectomy reduces recurrent pancreatitis episodes and hospital readmissions 1

Etiology-Specific Management

Hypertriglyceridemia-Induced Pancreatitis

• A serum triglyceride level >1000–2000 mg/dL is the identifiable risk factor 6, 7
• Initial treatment is similar to other causes: moderate fluid resuscitation, pain control, and nutritional support 8
• Hypertriglyceridemia is specifically treated with apheresis or insulin therapy when necessary 8
• Long-term management includes dietary restriction of fat and fibric acid derivatives 6, 7
• Reduction of triglyceride levels to well below 1000 mg/dL effectively prevents further episodes 6

Alcohol-Related Pancreatitis

• Brief alcohol-intervention programs lower subsequent alcohol intake by an average of 41 g per week 1
• The underlying cause should be identified in at least 75% of patients 1

Critical Pitfalls to Avoid

• Do not use aggressive fluid resuscitation rates exceeding 10 ml/kg/hr or 250–500 ml/hr, as this increases complications without improving outcomes 1
• Monitor continuously for fluid overload, which is associated with worse outcomes, increased mortality, and can precipitate or worsen ARDS 1
• Avoid continuing aggressive fluid resuscitation if lactate remains elevated after 4L of fluid; perform hemodynamic assessment 1
• Do not administer prophylactic antibiotics in mild, moderately severe, or severe acute pancreatitis 1, 5
• Progressively wean IV fluids rather than stopping abruptly to prevent rebound hypoglycemia 5, 1
• Avoid overfeeding; patients should receive 25 non-protein kcal/kg per day, increasing to no more than 30 kcal/kg per day 5

Treatments Lacking Proven Benefit

The following interventions have no demonstrated clinical benefit in acute pancreatitis and are not recommended: 1, 4

• Aprotinin 1
• Somatostatin 1
• Glucagon 4
• Fresh frozen plasma 1, 4
• Peritoneal lavage 1

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Treatment of Chronic Pancreatitis

For chronic pancreatitis, provide pancreatic enzyme replacement therapy with enteric-coated preparations (such as pancrelipase/CREON) at doses of 25,000–75,000 units of lipase per meal, use multimodal analgesia including opioids and adjunctive agents, implement dietary fat restriction, and address underlying causes such as alcohol cessation.

Pancreatic Enzyme Replacement Therapy

Pancrelipase (CREON) is the FDA-approved pancreatic enzyme product for treatment of exocrine pancreatic insufficiency due to chronic pancreatitis. 9

• CREON consists of enteric-coated spheres formulated to release pancreatic enzymes at pH ≥5.5 9
• The product contains a mixture of lipases, proteases, and amylases derived from porcine pancreatic glands 9
• Do not exceed 2,500 lipase units/kg/meal, 10,000 lipase units/kg/day, or 4,000 lipase units/g fat ingested/day in pediatric patients >12 months of age 9
• Dosages exceeding 6,000 lipase units/kg/meal have been associated with fibrosing colonopathy and colonic strictures in pediatric patients <12 years of age 9

Administration Guidelines

• Do not crush or chew CREON capsules or mix contents in foods with pH >4.5, as this disrupts the protective enteric coating and results in early enzyme release, oral mucosa irritation, and loss of enzyme activity 9
• Consume sufficient liquids (juice, water, breast milk, or formula) to ensure complete swallowing 9
• Visually inspect the mouth of pediatric patients <12 months of age to ensure no drug is retained and no oral mucosa irritation has occurred 9

Adverse Effects

Common adverse effects include: 9

• Gastrointestinal: abdominal pain, diarrhea, flatulence, constipation, nausea, fibrosing colonopathy, distal intestinal obstruction syndrome 9
• Metabolic: hyperuricosuria and hyperuricemia with high dosages 9
• Immune: anaphylaxis, asthma, hives, pruritus 9
• Hepatic: asymptomatic elevations of liver enzymes 9

Pain Management in Chronic Pancreatitis

• Use a multimodal approach combining opioids with adjunctive agents 4
• Consider epidural analgesia for refractory pain 4
• Pancreatic enzyme supplementation may reduce pain in some patients by decreasing pancreatic secretion 5

Dietary Measures

• Implement dietary restriction of fat to reduce steatorrhea and improve enzyme efficacy 5, 6
• Provide a diet rich in carbohydrates and proteins 5
• Ensure adequate caloric intake to prevent malnutrition 5

Nutritional Support in Severe Cases

• Parenteral nutrition may be indicated on rare occasions in patients with chronic pancreatitis due to pain-induced anorexia and continuing alcohol abuse 5
• Malnutrition is frequent due to increased resting energy expenditure 5
• Enteral nutrition is preferred when tolerated 5

Monitoring and Follow-Up

• Monitor for fibrosing colonopathy, especially in patients with a history of this complication 9
• Check for hyperuricosuria and hyperuricemia with chronic high-dose enzyme therapy 9
• Assess nutritional status regularly 5
• Screen for diabetes mellitus, which commonly develops in chronic pancreatitis 5