[Acute pancreatitis: Progress through Restraint?]

Abstract

Acute pancreatitis (AP) is a potentially life-threatening disease, often progressing in 2 phases: initial sterile inflammation, followed by later infected necrosis. Advances in care have shifted management toward a minimally invasive, step-up approach. AP is diagnosed based on typical abdominal pain, elevated lipase, or characteristic imaging - amylase is no longer essential. In hypertriglyceridemic AP, plasmapheresis offers no proven benefit. (Endo)sonography is mandatory. Contrast-enhanced CT should be delayed unless necrosis is suspected or diagnosis remains uncertain; optimal timing is ≥72h, ideally after 7 days. Prognostic tools (BISAP, Ranson) and markers (hematocrit, lactate, BUN) are insufficient to predict severe or necrotizing AP. Post-hoc, the revised Atlanta classification may be more effective than the determinant-based classification. Emergency ERC (<24h) is only warranted in cholangitis. Without cholangitis, ERC within 72h is adequate; biliary sphincterotomy and pancreatic stenting reduce post-ERC pancreatitis. Opioids are superior to NSAIDs and are first-line for analgesia. Early, goal-directed fluid resuscitation with balanced crystalloids improves outcomes, while excessive fluids (>3mL/kg/h) should be avoided. Enteral/oral nutrition within 24h reduces the risk of infected necrosis and is preferred over parenteral feeding. Antibiotic prophylaxis is not recommended, even in necrotizing AP; infected necrosis is rare in the first 2 weeks. Procalcitonin may support therapeutic decisions. Necrosis should be managed stepwise: antibiotics, then drainage, then delayed minimally-invasive necrosectomy. Endoscopic access is preferred; open surgery is obsolete. Outcomes improve significantly in specialized, high-volume centers with critical care, interventional endoscopy/radiology, and pancreatic surgery expertise.