One of the most important gastroenterological emergencies is acute
pancreatitis. It is classified into mild, moderately severe, and severe pancreatitis
depending on occurring complications. Establishing etiology and assessing disease
severity is the first step of the management.
Severe pancreatitis is encountered in 25% of patients and carries the highest mortality.
The therapy in these cases is structured on 4 interventions: fluid resuscitation,
nutritional support, pain management, specific measures addressed to etiology or
complications.
Fluid resuscitation for prevention of necrotizing pancreatitis is the foundation of early
management. Quality of life in these patients relies on prompt pain management. Early
enteral nutrition might reduce mortality, multiple organ failure and infection rate when
compared to late enteral nutrition and parenteral nutrition.
Pseudocysts and infected necrosis can complicate severe pancreatitis. These
symptomatic patients will need appropriate interventional maneuvers depending on
imaging and disease extension. Antibiotics should only be given when infection is
highly suspected, particularly when necrotizing pancreatitis is involved. Percutaneous
drainage is recommended when the collected necrosis has less than 1 month from
constitution. In walled-off pancreatic necrosis, endoscopic drainage and subsequent
necrosectomy is preferred to percutaneous drainage.
Surgery has to be taken into account after failure of endoscopical/percutaneous
procedures, intra-abdominal compartment syndrome, or acute on-going bleeding.
Keywords: Management, Pancreatic necrosis, Severe acute pancreatitis
