Acute Pancreatitis – Treatment
- Acute pancreatitis (AP) commonly leads to hospital admission.
- Management differs according to the underlying cause.
- 75% of cases are due to alcohol or gallstones/biliary tract disease in the developed world.
- Multiple other causes of pancreatitis include:
- Trauma, including ERCP;
- Metabolic abnormalities (e.g., hypercalcemia and hypertriglyceridemia);
- Viral infections (e.g., mumps, mononucleosis, hepatitis, coxsackie virus);
- Other conditions that block duct (e.g., tumour, congenital);
- Drugs, including antiretrovirals, chemotherapy, thiazide diuretics, sulfonamides, and azathioprine;
- Scorpion sting;
- Supportive care is mainstay of treatment.
- Pancreatic necrosis occurs in 5-10% of patients and may progress to infected necrosis which is associated with mortality rates of up to 30%.
- Judicious approach; titrate to end organ perfusion.
- Ringer’s Lactate or Plasmalyte (risk of acidosis with large volumes of normal saline).
- MAP 65-85 mmHg
- Urine output 0.5-1mL/kg/h
- Lack of consensus on fluid resuscitation:
- Aggressive goal-directed approach appears beneficial for patients who present with mild disease.
- Conservative approach better for those with severe disease (risk of ARDS, abdominal compartment syndrome) and/or comorbidities such as renal or heart failure.
- Conservative approach: 2 – 4L balanced solution over 24 h, with IV fluid boluses for hypotension and hypovolemia as necessary.
- Vasoactive agents to maintain BP if indicated.
- Multimodal analgesia (NSAIDs, acetaminophen, opioids).
- Mild disease – start on oral acetaminophen or opioids if effective in ED.
- Severe uncontrolled pain – thoracic epidural analgesia.
- Keep patients NPO until severe abdominal pain resolves; however, bowel rest is no longer recommended for patients with AP and enteral/oral feeding should be initiated as soon as tolerated.
- Electrolyte repletion (Ca, Mg, glucose control)
- Prophylactic antibiotics are not recommended. However, antibiotics may be indicated in specific cases, including:
- Infected necrosis confirmed by FNA
- CT shows gas within collection
- Unstable patients with suspected sepsis but source is unknown
- Patients with co-existent infection (e.g., cholangitis, UTI, pneumonia).
Acute gallstone pancreatitis
A) Endoscopic retrograde cholangiopancreatography (ERCP):
- Used to remove stones associated with cholangitis or obstructing the common bile duct. Ideally done within 24-48 hours of admission.
- Alternative: percutaneous drainage tube.
- Not emergent and timing of procedure may vary according to disease severity (i.e., index admission surgery recommended in mild disease, delayed surgery in severe disease).
- Potential alternative: ERCP with sphincterotomy.
- Goal is to reduce triglyceride levels to < 11.3 mmol/L. Consultation with gastroenterology is important in these patients.
Criteria For Hospital Admission
Most patients with AP are admitted:
- Older patients with comorbidities
- Not tolerating oral intake
- Uncontrolled pain; require IV pain management
- Gallstone pancreatitis
- Abnormal vitals
- Organ dysfunction
- First AP episode (i.e., not recurrent)
Criteria For Transfer To Another Facility
Referral to a high-volume center is indicated if a patient requires interventional radiology, endoscopy (including EUS and ERCP), and/or surgery.
Rural centers may not have access to the necessary imaging for the complete work-up of AP depending on a patient’s presentation. In this context, transport for ultrasound, ERCP and/or MRCP may be required.
Criteria For Close Observation And/or Consult
Consider transfer to a monitoring unit if any of the following are present:
- Severe disease
- Organ dysfunction
- Continued need for aggressive fluid resuscitation ([Hb]>160, [HCT]>0.500)
- An increased BMI of >30 (or >25 in Asian populations) further lowers the threshold for transfer
Consider admission to ICU in the following cases:
- Moderately severe pancreatitis (complications and/or transient organ failure)
- Persistent fluid resuscitations requirements
- Significant electrolyte abnormalities
- On-going SIRS
- Other risk factors for decompensation (e.g. elderly)
- Patients with acute gallstone pancreatitis who have obstruction of the common bile duct or cholangitis should be referred for ERCP, endoscopic ultrasound (EUS), or MRCP.
- Patients where hypertriglyceridemia is the underlying etiology of their AP.
- Patients with severe infected pancreatic necrosis.
Criteria For Safe Discharge Home
Discharge can be considered in patients with AP if their pain is adequately managed, they can tolerate oral intake and the underlying etiology is not gallstones/biliary tract disease.
- Provide oral fluids to patients with mild disease in ED before discharge to ensure tolerance.
- In cases where the underlying etiology was unknown at the time of discharge, follow-up with a gastroenterologist is indicated.
Indications for re-evaluation prior to discharge
- Intolerance of oral fluid
- Severe GI symptoms
- Persistent pain
Referral to counselling
- Recommended in cases where alcohol abuse is a concern.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Clinical practice guideline: evidence-based recommendations that reflect findings from RCTs, systematic reviews and meta-analyses (see guidelines for grading of individual recommendations).
Approach to fluid resuscitation in patients with AP: Resources suggest limited studies and lack of consensus regarding most effective approach.
Besinger B, Stehman CR. Pancreatitis and Cholecystitis. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020. Accessed November 23, 2020.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 05, 2020
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