Emergent Management of Pancreatitis 

Pancreatitis is an inflammatory process in which pancreatic enzymes autodigest the gland. Patients can present in the emergency department (ED) with acute pancreatitis, in which the pancreas can sometimes heal without any impairment of function or any morphologic changes, or they may present with chronic pancreatitis, in which individuals suffer recurrent, intermittent attacks that contribute to the functional and morphologic loss of the gland.

See also the following:

• Acute Pancreatitis
• Chronic Pancreatitis
• Pediatric Pancreatitis

Most of the pancreatitis cases presenting to the emergency department (ED) are treated conservatively, which includes fluid resuscitation, pain management, and sepsis control. Approximately 80% of patients with pancreatitis respond to such treatment.^[1]

Fluid resuscitation includes the following:

• Monitoring the patient's fluid intake/output accurately and electrolyte balance
• Infusion with crystalloids or other fluids, such as packed red blood cells (PRBCs), particularly in the case of hemorrhagic pancreatitis
• Placement of central lines and Swan-Ganz catheters for patients with severe fluid loss and very low blood pressure

If the patient is not vomiting well, a nasogastric (NG) tube is not necessary, but if the patient is vomiting continuously, then an NG tube is warranted for symptomatic relief and to avoid aspiration.

Analgesic and antibiotic administration

Analgesics are used to relieve pain. Meperidine is preferred over morphine because of the greater spastic effect of morphine on the sphincter of Oddi.^[2]

Antibiotics are used in severe cases associated with septic shock or when computed tomography (CT) scanning indicates that a phlegmon of the pancreas has evolved. Other conditions, such as biliary pancreatitis associated with cholangitis, also need antibiotic coverage. The preferred antibiotics are the ones secreted by the biliary system, such as ampicillin and third-generation cephalosporins.

Respiratory monitoring

Continuous oxygen saturation should be monitored by pulse oximetry, and acidosis should be corrected. When tachypnea and pending respiratory failure develops, intubation should be performed.

Inpatient transfer

Transfer patients with Ranson scores of 0-2 to a hospital floor.

Transfer patients with Ranson scores 3-5 to an intensive care unit (ICU).

Transfer patients with Ranson scores higher than 3 to an ICU, with emergency surgery as a possibility, depending on the patient's progress and findings on abdominal CT scanning.

Computed tomography (CT)-guided aspiration of necrotic areas may be necessary. Endoscopic retrograde cholangiopancreatography (ERCP) may be indicated for common duct stone removal.

Consult a general surgeon in the following cases:

• For a phlegmon of the pancreas, surgery can achieve drainage of any abscess or scooping of necrotic pancreatic tissue; this should be followed by postoperative lavage of the pancreatic bed
• In patients with hemorrhagic pancreatitis, surgery is indicated to achieve hemostasis, particularly because major vessels may be eroded in acute pancreatitis
• Patients whose condition fails to improve despite optimal medical treatment or patients who push the Ranson score even further are taken to the operating room; surgery in these cases may lead to a better outcome or confirm a different diagnosis: One study suggested a minimally invasive step-up approach was associated with less complication, although mortality was similar in the open and minimally invasive groups^[3]
• In biliary pancreatitis, a sphincterotomy (ie, surgical emptying of the common bile duct) can relieve the obstruction; a cholecystectomy may be performed to clear the system from any source of biliary stones
• In cases of mild gallstone pancreatitis, one small study of 50 patients found early gallbladder removal was safe and associated with shorter hospital stay^[4]