• 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);
  • Pregnancy;
  • Lupus;
  • Other conditions that block duct (e.g., tumour, congenital);
  • Drugs, including antiretrovirals, chemotherapy, thiazide diuretics, sulfonamides, and azathioprine;
  • Scorpion sting;
  • Idiopathic.
• 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%.

Supportive care

Fluid resuscitation

• Judicious approach; titrate to end organ perfusion.
• Ringer’s Lactate or Plasmalyte (risk of acidosis with large volumes of normal saline).
• Monitor:
  • 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.

Pain management

• 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.

Additional considerations

• 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.

B)  Cholecystectomy:

• 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.

Hypertriglyceridemia

• Goal is to reduce triglyceride levels to < 11.3 mmol/L. Consultation with gastroenterology is important in these patients.

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)

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.

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)

Gastroenterology consultation:

• 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.

Surgical consultation:

• Patients with severe infected pancreatic necrosis.

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.

Endoscopic Retrograde Cholangiopancreatography (ERCP) – Video

1. Acute Pancreatitis – an overview. ScienceDirect Topics.

   
   

2. Greenberg JA, Hsu J, Bawazeer M, et al. Clinical practice guideline: Management of acute pancreatitis. Can J Surg. 2016;59(2):128-140. 

   
   

3. Buxbaum J, Quezada M, Da B, et al. Early aggressive hydration hastens clinical improvement in mild acute pancreatitis. Am J Gastroenterol. 2017;112(5):797-803. 

   
   

4. 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.

   
   

5. Waller A, Long B, Koyfman A, Gottleib M. Acute pancreatitis: Updates for emergency clinicians. J Emerg Med. 2018;55(6):769-779. 

   
   

6. Swaminathan A. Acute pancreatitis. CORE EM. Published March 14, 2018.

   
   

7. Berkowitz R, Rose G. Pancreas. In: Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Elsevier; 2018:1104-1111.e2. Accessed December 1, 2020.