Treatment

• Fluids and infusion rate

  • Crystalloids such as normal saline (NS) or lactated Ringer's solution (LR) are preferred.

• Monitoring

  • Monitor vitals, oxygen saturation, and urine output.

  • Obtain laboratory studies (CBC, BMP, HCT) every 6–12 hours to monitor adequacy of fluid resuscitation and tissue perfusion.

  • Perform serial physical examination to assess for abdominal compartment syndrome.

• Replete electrolytes as needed.

Intravenous fluid resuscitation in the first 12–24 hours has the greatest impact on the clinical outcome of patients with acute pancreatitis.

• Analgesics

  • NSAIDS (e.g., ketorolac, diclofenac, ibuprofen)

  • Opioids (e.g., meperidine, hydromorphone, morphine)

• Antiemetics as needed (e.g., ondansetron, metoclopramide)

Prophylactic antibiotics are not recommended, and should only be used in patients with evidence of infected necrosis.

• Early oral feeding: Begin as soon as tolerated (i.e., not causing pain, nausea, or vomiting), ideally within 24 hours.

• Enteral tube (nasogastric or nasojejunal): preferred over parenteral nutrition if patients cannot tolerate oral intake

• Parenteral nutrition (total or partial): only in patients who cannot tolerate enteral feeds (e.g., those with persistent paralytic ileus)

Bowel rest is no longer routinely recommended. Enteral nutrition, via oral route or enteral tube, should be initiated as early as tolerated.

• Therapeutic ERCP

  • Indication: biliary pancreatitis associated with cholangitis or persistent CBD obstruction

  • Timing: Urgent therapeutic ERCP (within < 24 hours) is indicated if there is concurrent cholangitis.

  • Procedure: sphincterotomy and stone removal; see “Treatment of choledocholithiasis”

  • Complications: aggravation of pancreatitis, perforation, hemorrhage

• Cholecystectomy

  • Indication: all patients with biliary pancreatitis to prevent recurrence

  • Timing: recommended during the initial admission for patients with mild biliary pancreatitis

• Initiate measures to rapidly decrease triglyceride levels alongside fluid resuscitation and analgesia.

  • Insulin therapy

  • Plasmapheresis and hemofiltration

• Evaluate for secondary causes of hypertriglyceridemia ; consider screening for familial hypertriglyceridemia if none are present.

• Long-term management

  • Initiate long-term lipid-lowering therapy e.g., with fibrates, as soon as tolerated to prevent recurrences.

  • Dietary and lifestyle modifications

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• Check magnesium and phosphorus levels and replete as needed.

• Vitamin supplementation (thiamine, pyridoxine)

• Provide counseling on alcohol use disorder before discharge.