Seek expert advice.
Mild pancreatitis patients may receive outpatient care, but majority should be hospitalised for supportive therapy and optimal management. Patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support
Initial treatment is essentially supportive and includes early fluid resuscitation, analgesia, and nutritional support.
- during the first 24 hours, blood pressure, urine volume, pulse and respiratory rate, are checked hourly, and temperature and blood glucose, 4-6 hourly.
- fluid management
- Ringer’s lactate is recommended by the International Association of Pancreatology, while Hartmann’s solution is an alternative widely used in the UK
- consensus opinion is that 2.5-4 litres in 24 hours is necessary to restore circulating volume and urine output but the rate of fluid replacement should be determined by the clinical response
- response to fluid resuscitation is monitored by vital signs and urine output
- to achieve a urine output of ≥0.5 mL/kg/h and a target heart rate <120/min, and maintain hematocrit between 35% and 44%.
- in addition, patients who receive fluid resuscitation
- should have the head of the bed raised
- undergo continuous pulse oximetry
- receive supplemental oxygen - has shown to decrease the mortality more than half in patients older than 60 years
- analgesia
- it is important to provide adequate pain relief since respiratory function may be impaired by restriction of abdominal wall movement (due to abdominal pain)
- opioids have been used traditionally to provide analgesia
- morphine has known to cause sphincter of Oddi hypertension, hence exacerbate acute pancreatitis. There is little good evidence that this is clinically significant
- nutritional support
- hospitalised patients are usually placed on bowel rest
- laboratory and clinical observations do not supported this recommendation
- multiple studies have reported that
- bowel rest is associated with intestinal mucosal atrophy and increased infectious complications because of bacterial translocation from the gut
- early oral feeding results in shorter hospital stay, decreased infectious complications, decreased morbidity, and decreased mortality
- in mild pancreatitis
- enteral tube feeding shows no benefit in patients with mild pancreatitis hence in the absence of nausea and vomiting, and if the abdominal pain has resolved, oral feeding can be started
- do not need to begin with clear liquids and increase in a stepwise manner,
- may begin as a low-residue, low-fat, soft diet when the patient appears to be improving.
- three randomised trials have shown that in mild pancreatitis, the rate of complications is not increased by early oral nutrition
- in severe pancreatitis
- enteral nutrition is recommended over total parenteral nutrition to prevent local and systemic infective complications
- there is no conclusive evidence to support the use of enteral nutrition in all patients with severe acute pancreatitis but if nutritional support is required, the enteral route should be used if that can be tolerated
- most specialist units in the UK avoid early enteral nutrition and allow oral intake as tolerated.
- nasogastric route is tolerated by at least by 80% of the patients
- nasogastric and nasojejunal nutrition have similar safety and effectiveness profiles
- there is no specific enteral nutrition supplement or immunonutrition formulation which had any advantage on the outcome of severe acute pancreatitis.
- parenteral nutrition should be avoided, unless the enteral route is not available, not tolerated, or not meeting caloric requirements
* note the use of artificial nutrition versus no nutrition in acute pancreatitis is a controversial area and expert advice should be consulted
The role of antibiotic in acute pancreatitis
- there are no indications for the use of prophylactic antibiotics to prevent infection of necrosis or death
- extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia should be treated with antibiotics
- use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended
- in patients with infected necrosis (patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7–10 days of hospitalization)
- antibiotic treatment should be guided by sensitivity of cultured organisms when available or empiric use of antibiotics after obtaining necessary cultures for infectious agents
- antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in delaying or sometimes totally avoiding intervention, thus decreasing morbidity and mortality
Surgical treatment in acute pancreatitis:
- ERCP
- early endoscopic retrograde cholangiopancreatography should be considered in patients with coexisting cholangitis or biliary obstruction
- a Cochrane review carried out regarding the routine use of early endoscopic retrograde cholangiopancreatography in patients with acute gallstone pancreatitis (irrespective of predicted severity) did not find any evidence that it affects mortality and local or systemic complications
- cholecystectomy
- cholecystectomy for gallstones should ideally be carried out during the index admission with acute pancreatitis, after the initial symptoms have resolved.
- early cholecystectomy does not increase the risk of complications secondary to surgery
- recommended time limit between presentation and surgery is arbitrary but the shorter the interval the lower the risk.
- patients who experience a severe attack or in whom there is an ongoing intra-abdominal inflammatory changes, cholecystectomy should probably be delayed at least six weeks after discharge from hospital until active inflammation subsides
- percutaneous aspiration or surgical debridement (necrosectomy)
- patients with severe pancreatitis and infected necrosis or persistent fluid collections require intervention to completely debride all cavities containing necrotic material / drainage of pancreatic fluid collection
- a step up approach is recommended with percutaneous drainage as the initial step followed by minimally invasive surgical necrosectomy if needed
- in stable patients drainage should be delayed preferably for 3-5 weeks to allow development of a fibrous wall around the necrosis (walled-off necrosis) (1,2,3)
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