Diagnosis
The diagnosis of acute pancreatitis is usually based on two of the following three items: (1) abdominal pain consistent with disease; (2) serum amylase and/or lipase three times higher than normal on line; and (3) typical abdominal imaging.
Enhanced CT and MRI should be limited to patients whose diagnosis is unclear or whose symptoms do not improve within 48-72 hours of admission.
Etiology
Abdominal ultrasonography should be performed in all acute pancreatitis.
If there are no manifestations of gallstones and no history of heavy alcohol consumption, blood should be drawn for triglyceride testing, and hyperlipidemic pancreatitis should be considered if the triglyceride level is higher than 1000 mg/dl.
Patients older than 40 years of age should consider the possibility of acute pancreatitis caused by pancreatic tumors.
Endoscopy should be performed with caution in patients with acute idiopathic pancreatitis because the risks and benefits of endoscopy in such patients are not known.
Patients with idiopathic pancreatitis should be referred to a specialized pancreatic disease clinic.
Genetic testing should be considered in younger patients (less than 30 years old) with a family history of pancreatic disease if no specific etiology can be found.
Initial disease and risk assessment
Hemodynamic assessment is performed immediately at the onset of the disease, and resuscitation measures are performed immediately if necessary.
Based on the disease condition assessment, patients are classified as high-risk or low-risk to facilitate guiding their admission, such as the need for admission to the intensive care unit.
Patients with organ failure present should be admitted to the intensive care unit if available.
Initial treatment
Unless cardiovascular and renal disease is present, all patients should be treated with adequate rehydration, i.e., 250-500 mL per hour isotonic crystalloid infusion. Adequate intravenous rehydration is most effective within the first 12-24 hours; later is of little benefit.
Faster rehydration therapy (popping) is required in patients who present with fluid deficiencies, such as hypotension and increased heart rate.
Lactated Ringer’s solution may be the best crystalloid rehydration fluid.
Fluid rehydration should be reassessed every 6 hours for 24 to 48 hours after admission. The goal of adequate fluid rehydration should be to be able to be blood urea nitrogen reduction.
ERCP in acute pancreatitis
ERCP should be performed within 24 hours of admission in acute pancreatitis with concomitant acute cholangitis.
In most patients with biliary pancreatitis who lack laboratory and clinical evidence of bile duct obstruction, ERCP is mostly not required.
In the absence of cholangitis and jaundice, MRCP or abdominal ultrasound should be chosen for screening if common bile duct stones are highly suspected, and diagnostic ERCP is not preferred.
In patients at high risk of pancreatitis after ERCP, pancreatic duct stents or anal non-steroidal anti-inflammatory drugs (NSAIDs) should be placed for prophylaxis.
Use of antibiotics for acute pancreatitis
Antibiotics should be given to patients with extra-pancreatic infections, such as cholangitis, duct-acquired infections, bacteremia, urinary tract infections, and pneumonia.
Routine prophylactic antibiotic application is not recommended for patients with acute severe pancreatitis.
Prophylactic antibiotics are not recommended for the prevention of infectious necrosis in patients with aseptic pancreatitis.
Infectious necrosis should be considered in patients with pancreatic or extra-pancreatic necrosis that worsens 7-10 days after admission or does not respond to treatment. In such patients, (1) Gram staining and culture using CT-guided fine needle aspiration to guide antibiotic administration; or (2) empirical antibiotic application.
In patients with concomitant infectious necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazoles may help delay or avoid further interventions and therefore reduce disability and mortality.
Prophylactic or therapeutic antibiotic use along with conventional antifungal therapy is not recommended.
Nutrition in acute pancreatitis
In mild acute pancreatitis, if there is no nausea and vomiting, the abdominal pain can be immediately fed by mouth if it disappears.
In mild acute pancreatitis, it is equally safe to start with a low-fat solid diet and a liquid diet.
In severe acute pancreatitis, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided unless enteral nutrition is not available, cannot be tolerated or does not meet caloric requirements.
Nasogastric nutrition and nasojejunal nutrition are comparable in safety and efficacy.
Surgery for acute pancreatitis
If gallbladder stones are found in patients with mild acute pancreatitis, cholecystectomy should be performed before discharge to prevent recurrence of acute pancreatitis.
In patients with necrotizing biliary pancreatitis, cholecystectomy should be considered after the acute inflammation has subsided and the fluid accumulation has disappeared or stabilized in order to avoid infection.
Asymptomatic pseudocysts with pancreatic or extra-pancreatic necrosis do not require special treatment regardless of volume, site and extent.
In patients with stable infected necrosis, surgical, interventional and/or endoscopic drainage should be postponed for at least 4 weeks to allow for liquefaction of the contents and formation of the fibrous envelope.
In patients with symptomatic infected necrosis, minimally invasive approaches for necrolysis removal are recommended.