Management of Acute Pancreatitis

Classification and Initial Assessment

Pancreatitis is classified as mild (80% of cases, <5% of deaths) or severe (20% of cases, 95% of deaths) based on objective criteria 1, 3
Laboratory markers for assessment include lipase, amylase, white blood cell count, C-reactive protein, and procalcitonin (PCT is most sensitive for detecting pancreatic infection) 4
Imaging options include ultrasound, contrast-enhanced CT, MRI, and endoscopic ultrasound 4

Patients can be managed on a general ward with basic monitoring of vital signs 2, 3
Intravenous fluids should be administered via peripheral venous access, with possible nasogastric tube placement 3
Antibiotics should NOT be administered routinely as there's no evidence they affect outcomes in mild cases 3
Regular diet can be advanced as tolerated with oral pain medications 4
Routine CT scanning is unnecessary unless clinical deterioration occurs 3

All cases should be managed in an HDU or ITU setting with full monitoring and systems support 1, 2
Initial management requires full resuscitation and a multidisciplinary approach 1
Required monitoring includes peripheral venous access 5, central venous line for fluid administration and CVP monitoring 5, urinary catheter 6, nasogastric tube 6, and regular arterial blood gas analysis 5
Fluid resuscitation is crucial in preventing systemic complications, with moderate fluid resuscitation preferred over aggressive resuscitation 7
Oxygen saturation should be continuously monitored with supplemental oxygen administered to maintain arterial saturation >95% 7
Enteral nutrition (oral, nasogastric, or nasojejunal) should be provided 4
Routine prophylactic antibiotics are no longer recommended for all patients with acute pancreatitis, but may be considered in severe cases to prevent local and septic complications 1, 2, 4
Dynamic CT scanning with non-ionic contrast should be obtained within 3-10 days of admission 1
Follow-up CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement 8

Treatment depends on severity, presence of jaundice, or cholangitis 1, 6
For severe gallstone pancreatitis, urgent ERCP and sphincterotomy is indicated if the patient's condition fails to improve within 48 hours despite intensive resuscitation 1, 6
Immediate therapeutic ERCP is required in the presence of increasingly deranged liver function tests and signs of cholangitis 1, 6
ERCP should always be performed under antibiotic cover 5, 6

For patients with chronic pancreatitis, normal food supplemented by pancreatic enzymes is adequate for most patients, with a diet rich in carbohydrates and protein (1.0-1.5 g/kg) and moderate fat (30% of calories) 9
Enteral nutrition is indicated if patients cannot ingest sufficient calories due to pain, anatomical obstruction, or weight loss despite adequate normal food intake 9
Common pitfalls to avoid include routine use of antibiotics in mild pancreatitis 3, delaying ERCP in severe gallstone pancreatitis with cholangitis 6, and failing to provide adequate nutritional support 9