See the Guidelines section for guidelines recommendations from the American College of Gastroenterology, the American Gastroenterology Association, and the World Society of Emergency Surgery.
Medical management of mild acute pancreatitis is relatively straightforward. The patient is kept NPO (nil per os—that is, nothing by mouth), and intravenous (IV) fluid hydration is provided. Analgesics are administered for pain relief. Antibiotics are generally not indicated.
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If ultrasonograms show evidence of gallstones and if the cause of pancreatitis is believed to be biliary, a cholecystectomy should be performed during the same hospital admission. Feeding should be introduced enterally as the patient’s anorexia and pain resolves. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet. Systematic reviews and meta-analyses have shown that administration of enteral nutrition may reduce mortality and infectious complications compared with parenteral nutrition. [31] Although the ideal timing to initiate enteral feeding remains undetermined, administration within 48 hours appears to be safe and tolerated. [31]
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Serum amylase and lipase levels can be elevated in patients with brain injury (eg, cerebrovascular accident or brain trauma). These patients are generally cared for in an intensive care unit (ICU) and require mechanical ventilation. Pancreatic enzyme elevations may rise and fall considerably over many days to weeks. The elevation is believed to result from hyperstimulation of the pancreas via a central mechanism, but no evidence of acute pancreatitis is present on imaging studies.
Patients with severe acute pancreatitis require intensive care. Within hours to days, a number of complications (eg, shock, pulmonary failure, renal failure, gastrointestinal [GI] bleeding, or multiorgan system failure) may develop. The goals of medical management are to provide aggressive supportive care, to decrease inflammation, to limit infection or superinfection, and to identify and treat complications as appropriate.
Autoimmune pancreatitis is a rare condition. Corticosteroids should not be used to treat this condition in the short term in patients who are suspected of having autoimmune pancreatitis and who present with acute pancreatitis.
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No evidence-based guidelines specify when a patient should be transferred to a more experienced or skilled medical center. However, if severe acute pancreatitis is suggested either by the Atlanta criteria [2] or by a C-reactive protein (CRP) level above 10 mg/dL, Ranson score of 4 or higher, or Acute Physiology and Chronic Health Evaluation (APACHE) II score of 9 or higher, consider transfer to an institution where an intensivist staffs the critical care unit and an interested subspecialist experienced in the diagnosis and treatment of pancreatitis is available.
Further inpatient care depends on whether any of the complications of severe pancreatitis develop and how well patients respond to treatment. This ranges from a few days to several months of intensive care.
Patients can be discharged when their pain is well controlled with oral analgesia, they are able to tolerate an oral diet that maintains their caloric needs, and all complications have been addressed adequately.
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