Emergent Management of Pancreatitis 

Updated: Nov 22, 2019
Author: Ghattas Khoury, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP 

Overview

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

 

Emergency Department Management

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, 2, 3, 4, 5]

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.[6]

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).[7]

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.

 

Surgical Consultation

Computed tomography (CT)-guided aspiration of necrotic areas may be necessary. Endoscopic retrograde cholangiopancreatography (ERCP) may be indicated for common duct stone removal.[8]

Consult a general surgeon in the following cases[9] :

  • 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[10]

  • 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[11]

 

Guidelines

In June 2019, the World Society of Emergency Surgery (WSES) released updated guidelines for the management of severe acute pancreatitis.[12] Their strong recommendations are summarized below.

Severity grading

Grade 1C recommendations

Severe acute pancreatitis is associated with persistent organ failure (cardiovascular, respiratory, and/or renal), and high mortality. Both new classification systems, Revised Atlanta Classification and Determinant-based Classification of Acute Pancreatitis Severity, are similar in establishing the diagnosis and severity of acute pancreatitis.

Patients who have persistent organ failure with infected necrosis have the highest risk of death.

Patients with organ failures should be admitted to an intensive care unit (ICU) whenever possible.

Diagnostic laboratory parameters

The cut-off value of serum amylase and lipase is normally defined to be three times the upper limit.

A hematocrit level above  44% represents an independent risk factor of pancreatic necrosis (grade 1B recommendation).

Imaging

Grade 1C recommendations

On admission, perform ultrasonography (US) to determine the etiology of acute pancreatitis (biliary).

When doubt exists, computed tomography (CT) scanning provides good evidence of the presence or absence of pancreatitis.

Assess all patients with severe acute pancreatitis with contrast-enhanced CT (CE-CT) scanning or magnetic resonance imaging (MRI). Optimal timing for first the CE-CT assessment is 72-96 hours after symptomatic onset.

Consider MR cholangiopancreatography (MRCP) or endoscopic ultrasonography to screen for occult common bile duct stones in patients with unknown etiology.

Follow-up imaging (all grade 1C recommendations)

In severe acute pancreatitis (CT scan severity index ≥ 3), a follow-up CE-CT scan is indicated 7-10 days from the initial CT scan.

Additional CE-CT scans are recommended only if the patient's clinical status deteriorates or fails to show continued improvement, or when invasive intervention is considered.

Surgical intervention

The following are indications for surgical intervention (all grade IC recommendations):

  • As a continuum in a step-up approach after percutaneous/endoscopic procedure with the same indications

  • Abdominal compartment syndrome

  • Acute ongoing bleeding when an endovascular approach is unsuccessful

  • Bowel ischemia or acute necrotizing cholecystitis during acute pancreatitis

  • Bowel fistula extending into a peripancreatic collection

The following are indications for emergent endoscopic retrograde cholangiopancreatography (ERCP):

  • Routine ERCP with acute gallstone pancreatitis is not indicated (grade 1A recommendation).

  • ERCP in patients with acute gallstone pancreatitis and cholangitis is indicated (grade 1B recommendation).

Surgical strategies include the following:

  • Infected pancreatic necrosis: Percutaneous drainage as the first-line treatment (step-up approach) delays the surgical treatment to a more favorable time or results in complete resolution of the infection in 25-60% of patients; it is recommended as the first line of treatment (grade 1A recommendation).

  • Minimally invasive surgical strategies (transgastric endoscopic necrosectomy, video-assisted retroperitoneal debridement [VARD]): These result in less postoperative new-onset organ failure but require more interventions (grade 1B recommendation).

  • Mortality: There is insufficient evidence to support an open surgical, mini-invasive, or endoscopic approach (grade 1B recommendation).

Consideration of the timing of cholecystectomy includes the following:

  • Laparoscopic cholecystectomy during the index admission is recommended in mild acute gallstone pancreatitis (grade 1A recommendation).

  • When ERCP and sphincterotomy are performed during the index admission, the risk for recurrent pancreatitis is reduced; same admission cholecystectomy is still advised owing to an increased risk for other biliary complications (grade 1B recommendation).

Open abdomen

Considerations regarding open abdominal surgery include the following:

  • Clinicians should be cautious not to over-resuscitate patients with early severe acute pancreatitis and to measure intra-abdominal pressure regularly (grade 1C recommendation).

  • Avoid the open abdomen if other strategies can be used to mitigate or treat severe intra-abdominal hypertension (IAH) in severe acute pancreatitis (grade 1C recommendation).

  • It is recommended not to use the open abdomen after necrosectomy for severe acute pancreatitis (unless severe IAH mandates open abdomen as a mandatory procedure) (grade 1C recommendation).

  • It is recommend not to debride or undertake early necrosectomy if forced to undertake an early open abdomen due abdominal compartment syndrome or visceral ischemia (grade 1A recommendation).

  • The use of negative pressure peritoneal therapy is recommended for open abdomen management (grade 1B recommendation).

Timing for abdominal closure (grade 1B recommendation)

Early fascial and/or abdominal definitive closure should be the strategy for management of the open abdomen once any requirements for ongoing resuscitation have ceased, the source control has been definitively reached, no concern regarding intestinal viability persist, no further surgical reexploration is needed, and there are no concerns for abdominal compartment syndrome.