Acute Pancreatitis

TREATMENT

LOC

Mild acute pancreatitis

(No organ failure, no local or systematic complications, no signs of peritonitis, normal serum creatinine,  normal  haematocrit  [not  increased]

Early aggressive fluid resuscitation and acid-base balance

• Prevent volume depletion (adequate fluids with Ringer’s Lactate). Give 5-10 ml/kg/hour or 250-500 ml of isotonic crystalloids in the first 12-24 hours or urine output of at least 0.5 ml/kg/hour
• Give IV fluids to correct metabolic and electrolyte disturbances and to prevent hypovolaemia and hypotension
• Monitor electrolytes
• Goal is to decrease haematocrit and BUN in 48 hours, evaluate every 4-6 hours

Pain control

• Opioids, paracetamol, epidural anaesthesia (avoid NSAIDs)
  • Rectal/IV paracetamol 500 mg 6-8 hourly
  • or Pethidine 25-100 mg SC or IM or 25-50 mg slow Repeat prn every 4-6 hours
  • IV morphine 1-3 mg every 4 hours
  • Be aware of complications e.g. constipation, dysphagia, respiratory depression, confusion

Emesis

• Anti-emetics as appropriate
  • Metoclopramide 10 mg IV/IM every 8 hours
• Pass a nasogastric tube for suction when persistent vomiting or ileus occurs

HC4

Feeding and nutrition

• No feeding by mouth until signs and symptoms of acute inflammation subside (i.e. cessation of abdominal tenderness and pain, return of hunger and well-being)
• Provide energy with dextrose 50% 300-500 ml a day (add 50 ml to 500 ml Normal saline) to prevent muscle wasting
• Start early oral re-feeding on demand, start within 48-72 hours as soon as the patient is able and can tolerate feeds
• Start with clear liquids, then low fat semi-solid feeds then a normal diet – according to tolerance
• Monitor daily for vital signs, fluid intake, urinary output, and GI symptoms
• If oral feeding not possible, consider peripheral parenteral and central parenteral nutrition

Glycaemic control (hyperglycaemia is common)

• Keep serum blood sugar between 6-9 mmol/l
• Avoid hypoglycemia

HC4

Antibiotics

• Avoid inappropriate use of antibiotics and other medications e.g for prophylaxis
• In case of specific infection, e.g. biliary sepsis, pulmonary infection, or UTI, treat vigorously with appropriate antibiotic therapy

Other measures

• Address the underlying cause as is appropriate
• Stop alcohol or drugs
• Mobilisation
• Evaluation for gallstones by ultrasound scans
• Manage complications e.g. acute peri-pancreatic fluid collections, acute necrosis, pseudocyst

HC4

Moderately acute pancreatitis

• Transient organ failure (< 48 hours)
• Local or systematic complications without persistent organ failure

Severe acute pancreatitis

• Persistent organ failure (> 48 hours)
• Either single or multiple organ failure

Treatment as above plus

• Refer or consult with specialist at higher level
• HDU/ICU ( monitoring and nursing)
• Volume resuscitation
• Pain management
• Nutrition/ re-feeding
• Glycaemic control
• Nasogastric tube
• Oxygen / mechanical ventilation
• Renal replacement
• Address the cause where possible
• Manage complications as appropriate e.g. acute peri-pancreatic fluid collection, acute necrosis, pseudocyst

RR