Acute pancreatitis approach

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

Overview

The mainstay of treatment in acute pancreatitis involves pain control, bowel rest (NPO or nothing by mouth), and fluid resuscitation. Assessment of the re-introduction of feeding and nutritional support must be made subsequently based on clinical improvement and imaging findings. Serial cross sectional imaging may be used to determine the need for surgical intervention secondary to complications. Antiobiotics may only be used in cases when infection is suspected or confirmed. Clinicians must note that imaging findings almost always lag the clinical findings. Clinicians must make decisions primarily based on the patient's clinical condition. Cross-sectional imaging modalities may shed light to the local complications associated with acute pancreatitis and minimally invasive surgery may be performed to manage some complications (e.g. pancreatic necrosis).

Approach to Therapy

According to the American college of gastroenterology, following are the guidelines for initial assessment and risk stratification for acute pancreatitis:

Recommendation	Evidence Level	Strength of Recommendation
Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed	Moderate	Strong
Risk assessment should be performed to stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting	Moderate	Conditional
Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible	Low	Strong

Intrinsic patient related risk factors
Patient characteristics	Age >55 years
	Obesity (BMI>30kg/m2)
	Altered mental status
	Comorbid disease
The systemic inflammatory response syndrome (SIRS) Presence of >2 of the following criteria	Pulse >90 beats/min
	Respirations >20/min or PaCO2 >32mmHg
	Temperature >38°C or <36°C
	WBC count >12,000 or <4000 cells/mm3 or >10%  immature neutrophils (bands)
Laboratory findings	BUN >20 mg/dl
	Rising BUN
	HCT >44%
	Rising HCT
	Elevated creatinine
Radiology findings	Pleural effusions
	Pulmonary infiltrates
	Multiple or extensive extrapancreatic collections