Principles of managing acute pancreatitis
Acute pancreatitis should be managed in hospital because the potential for serious sequelae is high. Mortality is approximately 2%—patients with severe necrotising pancreatitis are at greatest risk.
Initial management of all patients with acute pancreatitis, regardless of severity, includes fluid administration and analgesia. Additional considerations are required for patients with complications of acute pancreatitis or associated conditions (eg acute [ascending] cholangitis).
The use of antibiotics to prevent infection in patients with acute pancreatitis (prophylactic antibiotics) is not recommended for acute pancreatitis. A large meta-analysis assessing prophylactic antibiotics detected no reduction of infection or mortality1Wittau, 2011.
Inadequate hydration is a common cause of morbidity in patients with acute pancreatitis. Goal-directed fluid administration is recommended, aiming for normalised heart rate and blood pressure, and a urine output of at least 0.5 mL/kg/hour. Evidence to guide choice of rehydration fluid is limited; however, compound sodium lactate (Hartmann) solution is recommended in several guidelinesArvanitakis, 2018Crockett, 2018Working Group, 2013. For patients with significant comorbidities (eg cardiovascular, kidney or liver disease), rates of fluid administration and the type of fluid may require modification. Frequent clinical and biochemical assessment of the patient is required to ensure goals of fluid management are met and to avoid fluid overload.
For analgesia, use intravenous morphine or fentanyl; see Intravenous opioids for severe, acute nociceptive pain in adults for dosage.
Antiemetic therapy may also be required; see Antiemetic drugs in adults for dosages and precautions.
For patients with gallstone pancreatitis, cholecystectomy during the initial admission is recommended—delaying cholecystectomy is associated with increased readmission ratesda Costa, 2015.
For patients with alcohol-associated acute pancreatitis, advise the patient to stop drinking alcohol (see Disorders of alcohol use). Regular (6-monthly) motivational interventions against alcohol consumption can decrease the rate of recurrence of acute pancreatitis in these patientsNordback, 2009.
Fasting is no longer recommended for patients with acute pancreatitis; early oral feeding as tolerated results in shorter hospital staysEckerwall, 2007Moraes, 2010. Enteral nutrition via nasogastric tube should be used in patients who cannot tolerate oral feeding after 72 hours. Reserve enteral feeding via nasojejunal tube for patients with gastric outlet obstruction or intolerance to the nasogastric route. Parenteral nutrition is indicated when the enteral route is not possible or when feeding via the enteral route does not meet the patient’s calorie requirementsNordback, 2009.