Management of Acute Pancreatitis

Pathophysiology and Diagnosis

Acute pancreatitis is an inflammatory condition of the pancreas most commonly caused by gallstones or excessive alcohol consumption, with the severe form comprising about 20-30% of cases and hospital mortality rates of approximately 15% 2
The severity of acute pancreatitis is classified as mild, moderate, or severe based on the 2012 Atlanta classification, with severe cases having persistent organ failure 2
Infection of pancreatic and peripancreatic necrosis occurs in 20-40% of severe cases, significantly worsening outcomes 2
Mortality rates vary significantly based on complications, with infected necrosis with organ failure having a mortality rate of 35.2%, sterile necrosis with organ failure having a mortality rate of 19.8%, and infected necrosis without organ failure having a mortality rate of 1.4% 2

Basic monitoring requirements include regular hourly assessment of vital signs and continuous vital signs monitoring in high dependency care unit if organ dysfunction occurs 1
Target urine output should be greater than 0.5 ml/kg body weight 1
Regular monitoring of hematocrit, blood urea nitrogen, creatinine, and lactate is essential to assess adequate tissue perfusion 1

Avoid hydroxyethyl starch (HES) fluids as they increase the risk of multiple organ failure 4
Lactated Ringer's solution is preferred over normal saline, although the article does not provide a direct comparison with a citation, it is generally recommended in the context of fluid resuscitation

Early oral feeding (within 24 hours) is recommended in mild cases as tolerated 4
In patients unable to feed orally, enteral nutrition is strongly preferred over parenteral nutrition 4, 1
Both nasogastric and nasojejunal routes are acceptable for enteral nutrition 4, 1
If ileus persists for more than five days, parenteral nutrition will be required 1
Early enteral nutrition helps prevent gut failure and infectious complications 1

Pain control is a clinical priority in acute pancreatitis, with Dilaudid preferred over morphine or fentanyl in non-intubated patients 1
Consider epidural analgesia as an alternative or adjunct to intravenous analgesia 1
Patient-controlled analgesia (PCA) should be integrated with every pain management strategy 1
Avoid NSAIDs in patients with acute kidney injury 1

In patients with predicted severe AP and necrotizing pancreatitis, prophylactic antibiotics are not routinely recommended 4
However, antibiotics are warranted when specific infections occur (respiratory, urinary tract, biliary, or catheter-related) 1
All patients with persistent symptoms and >30% pancreatic necrosis, or with clinical suspicion of sepsis, should undergo image-guided fine needle aspiration (FNA) for culture 7-14 days after onset 5, 6
Intravenous cefuroxime is a reasonable choice for prophylaxis in severe cases when indicated 1

In acute biliary pancreatitis with cholangitis, urgent ERCP is recommended 4, 3
ERCP should be performed within 72 hours of pain onset in patients with severe gallstone pancreatitis, cholangitis, jaundice, or a dilated common bile duct 1
Cholecystectomy should be performed during the initial admission rather than after discharge in patients with acute biliary pancreatitis 4
For unfit patients, endoscopic sphincterotomy alone is adequate treatment 5, 6
Cholecystectomy should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved 5, 6

Routine CT scanning is unnecessary in mild cases unless there are clinical signs of deterioration 1
Dynamic CT scanning should be obtained in severe cases to identify pancreatic necrosis and guide management 1
Follow-up CT is recommended only if the patient's clinical status deteriorates or fails to show continued improvement 1

Infected necrosis is the most serious local complication with high mortality (40%) 1
Patients with infected necrosis require intervention to completely debride all cavities containing necrotic material 5, 6
Consider minimally invasive approaches before open surgical necrosectomy 1
Options include percutaneous drainage and surgical debridement with thorough removal of necrotic tissue 5, 6

Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1
A multidisciplinary team approach involving intensivists, surgeons, gastroenterologists, and radiologists is essential for optimal management 1
Each case should be managed in an individualized way by a specialist pancreatic team 1

Regular monitoring of vital signs and laboratory parameters is essential 1
Follow-up imaging is recommended to monitor the resolution of collections in severe cases 1
In patients with mild pancreatitis, further CT is only required if there is a change in clinical status suggesting a new complication 1