ACG: ‘Early aggressive hydration’ essential to avoid complications in acute pancreatitis
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Key takeaways:
- Initial management for acute pancreatitis should include “moderately aggressive” fluid resuscitation.
- Monitoring vital signs and urine output in the hours following admission will help avoid many complications.
A new ACG guideline published in The American Journal of Gastroenterology underscored that early management “is essential” to prevent complications such as organ failure and pancreatic necrosis in patients with acute pancreatitis.
“Acute pancreatitis is a very heterogenous disease and highly unpredictable,” Scott Tenner, MD, MPH, JD, FACG, director of The Greater New York Endoscopy Surgical Center and clinical professor of medicine at State University of New York, told Healio. “Patients with acute pancreatitis must be observed very carefully for the first 24 to 48 hours. Many patients, almost one-fifth, who initially present with what appears to be mild disease will develop a myriad of complications, including organ failure and/or pancreatic necrosis.”
![“Monitoring vital signs and urine output following [blood urea nitrogen] and [hematocrit], especially 6 hours from admission, will help clinicians avoid many of the complications from acute pancreatitis.” Scott Tenner, MD, MPH, JD, FACG](/~/media/slack-news/gastroenterology/misc/infographics/2024/0324/hgi0324tenner_graphic_01.jpg?w=800)
According to Tenner, current consensus is that most complications “can be prevented” by close observation and IV hydration.
“Monitoring vital signs and urine output following [blood urea nitrogen] and [hematocrit], especially 6 hours from admission, will help clinicians avoid many of the complications from acute pancreatitis,” he added.
To update the existing clinical guideline for the management of acute pancreatitis (AP), ACG experts used the population/problem-intervention-comparison-outcome format to develop 16 key questions that served as the basis for recommendations and key concepts. The Grading of Recommendations, Assessment, Development and Evaluation system was then used to evaluate the quality of evidence for recommendations made for the diagnosis, etiology and severity of AP.
Highlights from the 11 established recommendations include:
- Experts suggest use of transabdominal ultrasound among those with AP to evaluate for biliary pancreatitis. If the initial examination is inconclusive, a repeat ultrasound is recommended.
- Among patients with idiopathic AP, they suggest additional diagnostic evaluation with repeat abdominal ultrasound, MRI and/or endoscopic ultrasound.
- Initial management for AP should include “moderately aggressive” fluid resuscitation with additional boluses if there is evidence of hypovolemia. Lactated Ringer solution should be used for IV resuscitation over normal saline.
- Rectal indomethacin is recommended to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis among those at high risk; a pancreatic duct stent should be placed in these patients.
- Experts suggest against use of prophylactic antibiotics in patients with severe AP and against fine-needle aspiration among those with suspected infected pancreatic necrosis.
- Among patients with mild AP, experts recommend early oral feeding, within 24 to 48 hours, as tolerated compared with the traditional nothing by mouth approach. Further, initial feeding should include a low-fat solid diet rather than a stepwise liquid-to-solid approach.
“Despite intense research, acute pancreatitis remains one of the only diseases that has no medical treatment other than adequate hydration,” Tenner told Healio. “Novel medications that target the inflammatory process are needed. We also need to better assess the role of early aggressive hydration, that is within the first 6 to 12 hours, [since] almost all the studies address hydration up to 48 hours.”
He continued: “It seems pretty clear from the current research that the amount of fluid provided after the first 48 hours is of no benefit, except in relation to usual supportive care. However, based on basic science, laboratory and clinical trials, there is some evidence that aggressive hydration or even plasma volume expansion to perfuse the pancreas may be beneficial.”
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