Management of Acute Pancreatitis: Conservative Treatment and Step-Up Invasive Approaches—Evidence-Based Guidance for Clinicians

Abstract

Although acute pancreatitis is one of the most common conditions that physicians face in daily practice, different approaches are still being followed. Given that in 20–30% of cases, acute pancreatitis progresses to the severe form with single- or multiorgan failure and is often associated with admission to the intensive care unit, proper management is important. This article is aimed at emphasizing the importance of proper conservative treatment of acute pancreatitis and at focusing on intervention criteria in case of complications, analyzing additionally the step-up endoscopic and surgical approaches. The most common mistakes in conservative treatment include inadequate initial fluid resuscitation, abuse in the administration of antibiotics, insufficient analgesia, avoidance of oral feeding, and inappropriate use of imaging techniques. Moreover, the timing and indications for endoscopic retrograde cholangiopancreatography and cholecystectomy are crucial. Furthermore, in case of unsatisfying response to conservative treatment, which mainly happens during necrotic pancreatitis, early intervention is not indicated and a minimally invasive approach must be adopted firstly, 4 weeks after the onset of the disease, and before any surgical intervention. Each medical procedure has specific indications and must be used in the appropriate occasion. As a result, clinical doctors must be familiar both with the intervention criteria and the indications of each method. The proper management of acute pancreatitis is essential and life-saving. That is valid both for the conservative treatment and for the invasive approaches.

Comparison of clinical outcomes between aggressive and non-aggressive intravenous hydration for acute pancreatitis: a systematic review and meta-analysis

“…According to a number of international guidelines, early fluid resuscitation with predominantly isotonic crystalloid (i.e., normal saline or Ringer's lactate solution) is widely indicated for AP management to prevent hypovolemia and organ hypoperfusion, without waiting for hemodynamic worsening [7,8,11,12]. However, the guidelines for the design of fluid resuscitation protocols remain inconsistent when it comes to the infusion rate [12][13][14][15][16][17][18][19]. For example, the American College of Gastroenterology (ACG) guidelines suggest that aggressive intravenous hydration (250-500 ml/hour) should be given to all patients with AP in the first 12-24 h unless cardiovascular and/or renal comorbidities exist [11].…”