A succinct review (CE Forsmark et al. NEJM 2016; 375: 1972-81) provides some useful pointers regarding acute pancreatitis.

The review covers the causes, epidemiology, diagnosis, prediction of severity and management.  With regard to management:

• The authors advocate for aggressive fluid resuscitation during the initial 24 hrs -though care to avoid fluid overload.  “One trial suggested the superiority of Ringer’s lactate as compared with normal saline in reducing inflammatory markers.”
• “Total parenteral nutrition is…more expensive, riskier, and no more effective than enteral nutrition.”
• “In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started.”
• “A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods.”  Thus, most patients with mild acute pancreatitis can start a low-fat diet soon after admission, “in the absence of severe pain, nausea, vomiting and ileus.”
• By day 5, one can predict the need for enteral feeding.  Early initiation of nasoenteric feeding “is not superior to a strategy of attempting an oral diet at 72 hours, with tube feeding only if oral feeding is not tolerated” by day 5.
• “Whether an elemental or semielemental formula is superior to a polymeric formula is not known”
• “Prophylaxis with antibiotic therapy is not recommended for any type of acute pancreatitis unless infection is suspected or has been confirmed.”  Infection in necrotic fluid collection “is the main indication for therapy” but is rare in the first 2 weeks of illness.
• For pancreatitis triggered by gallstones, after removal of any residual stones in the ducts, “cholecystectomy performed during the initial hospitalization…reduces the rate of subsequent gallstone-related complications by almost 75%” compared to waiting for 25-30 days.

Related blog posts:

• Changing Practice Patterns with Pediatric Pancreatitis | gutsandgrowth
• Why an ERCP Study Matters to Pediatric Care | gutsandgrowth This post explains why LR may be best.
• Nutrition University / gutsandgrowth What are the nutritional management recommendations for acute pancreatitis? Justine Turner indicated that too many centers continue to rely on parenteral nutrition.  Yet, guidelines recommend the use of enteral nutrition due to lower risk of poor outcomes (eg. infections when NPO and on parenteral nutrition). ‘Resting pancreas is not helpful.’ With acute pancreatitis, enzyme secretion is reduced.  Her approach is to start nasogastric (NG) feedings at about 24 hours after presentation, as long as hemodynamically stable.  She indicated that nasojejunal (NJ) feedings can be done if NG is not well-tolerated.  NJ feedings are effective at reducing enzyme secretion.  However, Praveen Goday stated that his practice was often starting with NJ feeds.  “Sometimes there is only one shot” before the ICU team starts HAL.  Both physicians indicated that polymeric formulas were probably acceptable; however, starting with semi-elemental or elemental feedings are often done, again as a practical matter to minimize the likelihood of reverting to parenteral nutrition.

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