Acute pancreatitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – intravenous fluids

Back

1st line –

intravenous fluids

All patients need to be treated with intravenous hydration for the first 24 hours and monitored closely for early fluid losses, hypovolemic shock, and symptoms suggestive of organ dysfunction in the first 48-72 hours from presentation.[8]

Initial treatment of acute pancreatitis requires early intravenous hydration.[1][5][71][75][76][77][78][79] Clinicians should focus on a steady rate of initial resuscitation (no more than 1.5 mL per kg of body weight per hour) and should administer a bolus of 10 mL per kg, only if there are signs of hypovolemia.[72] Patients with acute pancreatitis may develop hypovolemia rapidly after admission and require fluid boluses and/or increases in the rate of hydration.[8] A balanced crystalloid (such as Ringer's lactate [Hartmann solution] or Plasma-Lyte®) may have benefits compared with normal saline.[8][47][81] Previously, aggressive early rehydration was recommended for all patients with acute pancreatitis but evidence now supports a moderate approach with close attention to vital signs, especially heart rate, with BUN and hematocrit evaluation at frequent intervals (within 6 hours of presentation and for the following 24-48 hours).[8][71][73]

Close monitoring is particularly recommended for certain patient groups such as older individuals and those with a history of cardiac and/or renal disease, who are more at risk from excessive intravenous hydration.[8]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Signs of cardiovascular, respiratory, or renal dysfunction may be present. Patients with organ failure and/or persisting systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit whenever possible.[8][28]

The definition of SIRS is met by the presence of at least two of the following criteria: pulse >90 beats per minute; respiratory rate >20 per minute or partial pressure of carbon dioxide (PaCO₂) <32 mmHg; temperature >100.4°F or <96.8ºF; WBC count >12,000 or <4000 cells/mm³, or >10% immature neutrophils (bands).[49]

The presence of persistent (>48 hours) single- or multi-organ failure defines acute pancreatitis as severe according to the revised Atlanta criteria.[8][28] In everyday clinical practice, the following parameters (from the original Atlanta criteria) may be used to establish organ failure: shock: systolic blood pressure <90 mmHg; pulmonary insufficiency: partial pressure of oxygen (PaO₂) ≤60%; renal failure: creatinine >2 mg/dL; gastrointestinal bleeding: >500 mL blood loss in 24 hours.[8]

It is critical to recognize the importance of organ failure in determining disease severity.[8] In the presence of SIRS-associated organ dysfunction, additional monitoring and organ support may be necessary (e.g., oxygen supplementation and/or ventilatory support for respiratory failure).

No patient should be classified as having mild disease until at least 48 hours after symptom onset as some patients who go on to develop severe disease present without signs of organ failure or local complications.[8]

Plus – analgesia

Back

Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Pain control with opioids may reduce the need for multimodal analgesia.[90] [ ] [Evidence C]

Fentanyl or morphine can be used, either for breakthrough pain or as patient-controlled analgesia. In mild cases, the standard World Health Organization pain ladder can be used to inform the selection, monitoring, and adjustment of analgesia.

Ketorolac, a nonsteroidal anti-inflammatory drug, can be used in patients with intact renal function. It should not be used in older patients because of the risk of adverse gastrointestinal effects.[91]

Primary options

morphine sulfate: 2.5 to 10 mg intravenously/intramuscularly/subcutaneously every 2-6 hours when required

fentanyl: 50-100 micrograms intravenously/intramuscularly every 1-2 hours when required

ketorolac: consult specialist for guidance on dose

Plus – nutritional support

Back

Plus –

nutritional support

Treatment recommended for ALL patients in selected patient group

Oral nutrition should resume as soon as pain and any nausea/vomiting begin to subside. Both the American College of Gastroenterology and the American Gastroenterological Association recommend oral feeding within 24 hours, if tolerated, in patients with acute pancreatitis.[8][85]

Enteral tube nutrition should be used for patients who are unable to feed orally; parenteral nutrition should be avoided.[96] Continuous enteral infusion is preferred over cyclic or bolus administration.[8] Small peptide-based medium chain triglyceride formulas can be used if standard formulas are not tolerated.[96]

Nasogastric tube feeding is recommended in preference to the nasojejunal route for most patients.[8][96][102] Patients at increased risk of aspiration should be put in a more upright position and placed on aspiration precautions.[8] Nasojejunal tube placement requires interventional radiology or endoscopy and thus has resource implications.[8]

No specific enteral nutrition formulation has been proven to be better than another in patients with acute pancreatitis.[103]

Consider – antiemetic

Consider – empiric intravenous antibiotics (if infection is confirmed or strongly suspected)

Back

Consider –

empiric intravenous antibiotics (if infection is confirmed or strongly suspected)

Treatment recommended for SOME patients in selected patient group

When an infection is suspected, antibiotics should be given while the source of the infection is being investigated.

Fever, tachycardia, tachypnea, and leukocytosis are associated with the systemic inflammatory response syndrome (SIRS) that may occur early in the course of acute pancreatitis. This clinical picture may be indistinguishable from sepsis.

Other infectious complications of acute pancreatitis include cholangitis, urinary tract infections, infected pseudocysts, fluid collections, and infected pancreatic necrosis.

If blood and other cultures are found to be negative and no source of infection is identified, antibiotics should be discontinued.

The American College of Gastroenterology and the American Gastroenterology Association recommend against the use of prophylactic antibiotics in patients with severe acute pancreatitis (or predicted severe acute pancreatitis).[8][85]

Choose an antibiotic that has good pancreatic penetration, such as a carbapenem (e.g., imipenem/cilastatin), a fluoroquinolone (e.g., ciprofloxacin), or metronidazole.[8][28] Imipenem/cilastatin is usually the first-line choice because it has good pancreatic penetration. Check local guidance on antibiotic stewardship.

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[106] Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, and unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

Primary options

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours, maximum 4000 mg/day

with gallstones; without cholangitis

Plus – cholecystectomy

with gallstones; with concurrent cholangitis

Plus – endoscopic retrograde cholangiopancreatography (ERCP)

Back

Plus –

endoscopic retrograde cholangiopancreatography (ERCP)

Treatment recommended for ALL patients in selected patient group

Patients with gallstone pancreatitis and concurrent cholangitis benefit from early ERCP. The benefit is seen in patients with sepsis complicated by organ failure who undergo the procedure within the first 24 hours from admission.[8][47][88][89] Although gallstones in the common bile duct are a common cause of acute pancreatitis, most gallstones readily pass to the duodenum and are lost in the stool. Persistent choledocholithiasis can lead to persistent pancreatic duct and/or biliary tree obstruction, leading to necrosis and/or cholangitis. Removal of obstructing gallstones from the biliary tree in patients with acute pancreatitis should reduce the likelihood of complications.

ERCP is not indicated for either mild or severe gallstone pancreatitis without cholangitis.[64][85] The risks of the procedure outweigh any potential benefits in this patient population.

ONGOING

deteriorating or failing to improve

1st line – ongoing supportive treatment

Back

1st line –

ongoing supportive treatment

Ongoing supportive care with intravenous fluids, analgesia, and in some cases an antiemetic may be required for an extended period. Patients with organ failure and/or systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit whenever possible.[8][28]

American College of Gastroenterology guidelines recommend computed tomography (CT) or magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) after 48 hours in patients who do not improve or whose symptoms worsen, to assess for necrosis.[8] Other guidelines recommend a delay of 72-96 hours after symptom onset before contrast-enhanced CT or MRI.[28][47]

Plus – ongoing nutritional support

Back

Plus –

ongoing nutritional support

Treatment recommended for ALL patients in selected patient group

In patients who are unable to feed orally, enteral tube nutrition should be used; parenteral nutrition should be avoided.[96]

Continuous enteral infusion is preferred over cyclic or bolus administration.[8] Small peptide-based medium chain triglyceride formulas can be used if standard formulas are not tolerated.[96]

Nasogastric tube feeding is recommended in preference to the nasojejunal route for most patients.[8][96][102]

with infected pancreatic necrosis

Plus – intravenous antibiotics

Back

Plus –

intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

All patients with confirmed or highly suspected infected necrosis should receive intravenous antibiotics.[47] Patients who are clinically stable should continue antibiotics for 30 days before further intervention is considered.[8]

Primary options

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours, maximum 4000 mg/day

Consider – catheter drainage (endoscopic or radiologic)

Consider – necrosectomy/debridement

Back

Plus –

drainage (endoscopic, radiologic, or surgical) and intravenous antibiotics

Treatment recommended for ALL patients in selected patient group

Pseudocysts do not appear until 2-4 weeks after the onset of an episode of acute pancreatitis.

If a pseudocyst becomes infected, it is best described as an abscess, which requires antibiotics and drainage.

Primary options

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours

Secondary options

ciprofloxacin: 400 mg intravenously every 12 hours

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours, maximum 4000 mg/day

Use of this content is subject to our disclaimer

Acute pancreatitis

Treatment algorithm

all patients

intravenous fluids

supportive care

analgesia

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

nutritional support

antiemetic

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

empiric intravenous antibiotics (if infection is confirmed or strongly suspected)

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

with gallstones; without cholangitis

cholecystectomy

with gallstones; with concurrent cholangitis

endoscopic retrograde cholangiopancreatography (ERCP)

deteriorating or failing to improve

ongoing supportive treatment

ongoing nutritional support

with infected pancreatic necrosis

intravenous antibiotics

Primary options

Secondary options

catheter drainage (endoscopic or radiologic)

necrosectomy/debridement

with sterile pancreatic necrosis

catheter drainage or necrosectomy/debridement

with symptomatic uninfected pseudocyst

drainage (endoscopic, radiologic, or surgical)

with infected pseudocyst (abscess)

drainage (endoscopic, radiologic, or surgical) and intravenous antibiotics

Primary options

Secondary options