Initial Management of Acute Pancreatitis

Severity Assessment

The American Gastroenterological Association recommends severity assessment should be performed immediately using objective criteria to guide appropriate management decisions 3, 4
Laboratory markers including hematocrit, blood urea nitrogen, creatinine, and liver function tests should be monitored as indicators of severity and adequate volume status 4
CT severity index can help stratify patients (scores 0-3: mild disease with 3% mortality; scores 4-6: moderate with 6% mortality; scores 7-10: severe with 17% mortality) 1, 5

The British Society of Gastroenterology recommends adequate prompt fluid resuscitation is crucial in preventing systemic complications and should be initiated immediately 1, 2, 4
Intravenous crystalloids (preferably Lactated Ringer's solution) should be administered to maintain urine output >0.5 ml/kg body weight 1, 4
The rate of fluid replacement should be monitored by frequent measurement of central venous pressure in appropriate patients 1, 2
Oxygen saturation should be measured continuously and supplemental oxygen administered to maintain arterial saturation greater than 95% 1, 2

The American College of Gastroenterology recommends can be managed on a general ward with basic monitoring of temperature, pulse, blood pressure, and urine output 6, 3
Peripheral intravenous line for fluids and possibly a nasogastric tube are required, but indwelling urinary catheters are rarely warranted 6, 3
Antibiotics should not be administered routinely as there is no evidence that their use in mild cases affects outcomes 6, 3, 4
Routine CT scanning is unnecessary unless there are clinical signs of deterioration 6, 3
Early oral feeding (within 24 hours) is recommended rather than keeping patients nil per os 4

The European Society of Gastrointestinal Endoscopy recommends should be managed in an HDU or ITU setting with full monitoring and systems support 6, 3, 7
Requires peripheral venous access, central venous line, urinary catheter, and nasogastric tube 6, 3
Strict asepsis should be observed in the placement and care of invasive monitoring equipment 6, 3
Regular arterial blood gas analysis is essential as hypoxia and acidosis may be detected late by clinical means alone 6, 3
Hourly monitoring of pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature is required 6, 3
Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast 6, 3, 4
Prophylactic antibiotics may be considered in severe cases with evidence of pancreatic necrosis, though evidence is mixed 2, 6, 4

The American Pain Society recommends pain control is a clinical priority and should be addressed promptly 4
A multimodal approach to analgesia is recommended, with intravenous opiates generally safe if used judiciously 4
NSAIDs should be avoided in patients with acute kidney injury 4

The European Society for Clinical Nutrition and Metabolism recommends for patients unable to tolerate oral intake, enteral nutrition is recommended over parenteral nutrition 4
Both gastric and jejunal feeding routes can be safely utilized 4
Total parenteral nutrition should be avoided but partial parenteral nutrition can be considered if enteral route is not completely tolerated 4

The American Society for Gastrointestinal Endoscopy recommends urgent ERCP (within 24 hours) should be performed in patients with concomitant cholangitis 4
Early ERCP (within 72 hours) is indicated for patients with high suspicion of persistent common bile duct stone, persistently dilated common bile duct, or jaundice 4

Using hydroxyethyl starch (HES) fluids in resuscitation - these should be avoided 4
Routine use of prophylactic antibiotics in mild pancreatitis - only indicated for specific infections 6, 3, 4
Keeping patients nil per os unnecessarily - early oral feeding is beneficial when tolerated 4
Relying on specific pharmacological treatments - there is no proven specific drug therapy for the treatment of acute pancreatitis 1, 2