What are the current guidelines for managing acute pancreatitis?

Management of Acute Pancreatitis

All patients with severe acute pancreatitis must be managed in an intensive care unit or high-dependency unit with full invasive monitoring, early enteral nutrition within 24 hours, and immediate referral to a specialist pancreatic center. 1, 2

Diagnosis and Initial Assessment

Establish the diagnosis within 48 hours of admission using two of three criteria: characteristic abdominal pain, serum lipase ≥3× upper limit of normal (lipase is preferred over amylase), and/or imaging findings consistent with pancreatitis. 3, 4

• Stratify severity within 48 hours using clinical impression, obesity, APACHE II score in the first 24 hours, CRP >150 mg/L, Glasgow score ≥3, or persistent organ failure after 48 hours. 3
• Determine etiology in at least 80% of cases; no more than 20% should remain idiopathic. 5, 3
• Reserve contrast-enhanced CT for patients in whom the diagnosis is unclear or who fail to improve clinically. 3, 4

Admission and Monitoring Criteria

Mild Pancreatitis (80% of cases)

• Manage on general medical wards with basic monitoring of temperature, pulse, blood pressure, and urine output. 5
• Peripheral IV access and possibly nasogastric tube are sufficient; urinary catheter rarely needed. 5

Severe Pancreatitis (20% of cases, 95% of deaths)

Immediate ICU/HDU admission is mandatory for: 2, 3

• Persistent organ failure (cardiovascular, respiratory, or renal dysfunction lasting >48 hours) 2
• Clinical deterioration despite adequate resuscitation within 48 hours 2
• Imaging showing >30% pancreatic necrosis 2

Essential invasive monitoring includes: 5, 2

• Central venous line for CVP monitoring and fluid administration 2
• Urinary catheter for hourly urine output measurement 2
• Nasogastric tube for gastric decompression and early feeding 2
• Hourly vital signs: pulse, blood pressure, CVP, respiratory rate, SpO₂, temperature 1, 2
• Regular arterial blood gas analysis to detect hypoxia and acidosis early 5, 2
• Swan-Ganz catheter for cardiocirculatory compromise or failed initial resuscitation (measures pulmonary artery wedge pressure, cardiac output, systemic vascular resistance) 5, 2

Fluid Resuscitation

Use goal-directed therapy with non-aggressive resuscitation at 1.5 mL/kg/hr following an initial bolus of 10 mL/kg. 3

• Target urine output >0.5 mL/kg/hr and reversal of tachycardia and hypotension. 2
• Avoid hydroxyethyl starch fluids, which increase risk of multiple organ failure. 3
• Early aggressive hydration is most beneficial within the first 12–24 hours and may have little benefit beyond. 4

Nutritional Support

Initiate oral feeding within 24 hours in patients without nausea, vomiting, or severe ileus—this reduces the need for necrosis-directed interventions by approximately 2.5-fold. 1, 3, 4

• Early feeding preserves the gut mucosal barrier and limits bacterial translocation, thereby lowering the risk of infected pancreatic necrosis. 1
• When oral intake is not feasible, provide enteral nutrition via nasogastric tube (successful in approximately 80% of cases) or nasojejunal tube—both routes are equally safe and effective. 1, 2, 3
• Enteral nutrition is strongly preferred over parenteral nutrition; enteral feeding markedly decreases infected peripancreatic necrosis (OR ≈ 0.28), single-organ failure (OR ≈ 0.25), and multiple-organ failure (OR ≈ 0.41). 1, 3
• Reserve parenteral nutrition only for patients who cannot tolerate enteral feeding after 5 days. 2, 3

Critical pitfall: Do not keep patients nil per os routinely; delayed feeding beyond 24 hours is associated with a 2.5-fold higher likelihood of requiring invasive interventions. 1

Pain Management

Use a multimodal approach: 3

• NSAIDs with acetaminophen for mild pain 3
• Weak opioids for moderate pain 3
• Consider epidural analgesia for severe pain requiring high-dose opioids for extended periods 1, 3
• Always prescribe laxatives when using opioids to prevent constipation 3
• Avoid NSAIDs in patients with acute kidney injury 1, 3

Antibiotic Management

Prophylactic antibiotics are NOT routinely recommended for preventing infection of pancreatic necrosis—high-quality randomized trials published after 2002 showed no reduction in infected necrosis or mortality. 5, 1, 3, 4

• Use antibiotics only for documented specific infections: cholangitis, respiratory infections, urinary infections, line-related sepsis. 5, 2, 3
• If prophylactic antibiotics are administered contrary to guideline advice, limit the course to a maximum of 14 days. 1, 2, 3
• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may delay intervention, decreasing morbidity and mortality. 4

Imaging Strategy

Perform contrast-enhanced CT at 6–10 days (not routinely earlier) in patients with: 2, 3

• Persistent organ failure 2, 3

• Clinical signs of sepsis 2

• Clinical deterioration 2, 3

• Use non-ionic contrast agents for all CT examinations. 1, 2

• In patients with >30% necrosis and persistent symptoms or suspected infection, obtain image-guided fine-needle aspiration for culture (diagnostic accuracy 89–100%). 1, 2, 3

Critical pitfall: Routine CT scanning in mild pancreatitis is unnecessary unless there are clinical or other signs of deterioration. 5

Management of Gallstone Pancreatitis

Perform urgent ERCP within 24–72 hours ONLY for patients with: 1, 2, 3, 4

• Cholangitis (fever, rigors, positive blood cultures) 2

• Jaundice with biliary obstruction 2

• Dilated common bile duct 2

• All patients undergoing ERCP should receive endoscopic sphincterotomy, regardless of stone detection. 2

• All patients with biliary pancreatitis must undergo cholecystectomy during the same hospital admission or within 2 weeks to prevent recurrence. 1, 2, 3, 4

Critical pitfall: Routine urgent ERCP for all gallstone pancreatitis without cholangitis provides no mortality benefit and should be avoided. 1

Management of Pancreatic Necrosis

Sterile Necrosis (mortality 0–11%)

• Manage conservatively with fluid resuscitation, nutritional support, and monitoring for complications. 1
• Sterile necrosis does not usually require intervention. 1

Infected Necrosis (mortality 30–40%)

Delay intervention until at least 4 weeks after disease onset whenever feasible—this timing is associated with lower mortality because necrosis becomes "walled-off" and demarcated from vital tissue, resulting in less bleeding and more effective necrosectomy. 1, 3

Indications for early intervention (<4 weeks): 1

• Abdominal compartment syndrome unresponsive to conservative management 1
• Acute ongoing bleeding when endovascular approach is unsuccessful 1
• Bowel ischemia or acute necrotizing cholecystitis 1

Indications for late intervention (≥4 weeks): 1

• Infected necrosis with clinical deterioration despite maximal medical therapy 1
• Persistent organ failure beyond 4 weeks 1

Use a step-up approach: start with percutaneous or endoscopic drainage and progress to minimally invasive necrosectomy if no improvement occurs. 1

Referral to Specialist Centers

Transfer to a specialist pancreatic center is mandatory for: 1, 2, 3

• Extensive necrotizing pancreatitis (>30% necrosis) 2
• Persistent organ failure requiring advanced organ-support modalities 2
• Complications requiring interventional radiology, advanced endoscopy, or pancreatic surgery 2

The specialist unit should maintain a 24/7 multidisciplinary team comprising surgeons, gastroenterologists, intensivists, interventional radiologists, and advanced endoscopists. 2

Mortality Targets and Outcomes

• Overall mortality should be <10%; <30% in severe pancreatitis. 5, 2, 3
• The overall mortality from necrotizing pancreatitis is 30–40%. 1, 2
• Specialist centers using aggressive surgical debridement for infected necrosis have reported mortality rates between 10–20%. 5, 1
• Sterile necrosis with organ failure has 19.8% mortality, while infected necrosis with organ failure has 35.2% mortality. 1

Critical pitfall: Delaying ICU admission increases mortality; early intensive monitoring improves outcomes. 2