Management of Severe Pancreatitis

Sjoerd H.W. van Bree^1*, Pieter R. Tuinman², Marc G. Besselink³ and Angelique M.E. de Man²

1. Department of Intensive Care, Gelderse Vallei Hospital, Ede, the Netherlands.

2. Amsterdam UMC, location Vrije Universiteit, department of intensive care, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands

3. Amsterdam UMC, location University of Amsterdam, department of surgery, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.

*Correspondence to: Sjoerd H.W. van Bree, Department of Intensive Care, Gelderse Vallei Hospital, Ede, the Netherlands.

Copyright

© 2025 Sjoerd H.W. van Bree, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 23 July 2025

Published: 01 Aug 2025

DOI: https://doi.org/10.5281/zenodo.16759036

Abstract:

Severe acute pancreatitis is a challenging disease for the clinician: the outcome is unpredictable and the long-lasting course of the attack is characterized by the emergence of life-threatening local complications and multiple distant organ failures. Patients are typically ill for an extended period and require numerous medical, surgical, endoscopical, radiological and nutritional interventions if they are to survive. All through the course of the treatment it is essential that one adopts a multidisciplinary approach, alongside keeping in mind that cognitive and emotional responses vary in patients, family and within the team of health care providers.

Keywords Pancreatitis; complications; intensive care; microbiological investigation; multidisciplinary approach; treatment.

Introduction

Severe acute pancreatitis is an alarming condition, which presents many challenges for critical care staff and is such a variable disease that it cannot be effectively managed by blindly following any given set of recommendations (1).

Background information on the management of patients with severe pancreatitis  can be found in the recently revised e-Learning course ‘Severe Acute Pancreatitis’ of the European Society Intensive Care Medicine (4).

Trials that are focused on reducing organ failure through immunomodulation still produce unsatisfactory results (2). A more basic understanding of the early inflammatory response is therefore needed. Recently, using multiomics techniques, four subtypes of molecular endotypes have been identified in patients with acute pancreatitis, resembling generalizable endotypes seen in ARDS patients (3).

Although fluctuating due to environmental and diagnostic differences, the true incidence of acute pancreatitis is steadily increasing. Most countries in the Western world have reported a rise in the incidence over the last decades. Two peaks of mortality occur; the “early” and “late” phase. The early peak is caused by a sterile inflammatory process starting from the pancreas and progressing to a systemic inflammatory response syndrome (SIRS) with a mortality rate of up to 50%. The late peak of mortality is usually secondary to complications such as infections of the pancreatic and peripancreatic necrotic debris.

Complications

With regard to patients with severe acute pancreatitis, there is no other abdominal problem where clinical outcome is so unpredictable, as severe local and subsequent remote complications may arise unexpectedly. It is therefore of utmost importance to be constantly aware of loco-regional complications. The most common late complications are infection of the necrotic pancreas, pseudocysts, fistulas, hemorrhage, venous splanchnic thrombosis and intestinal problems (Table 1).

Establish the diagnosis of infected necrosis by contrast?enhanced CT. The “step-up” approach is crucial for infected pancreatic necrosis to reduce complications and invasive interventions. In case of confirmed or clinically highly suspected infection, antibiotics should be started. For patients with insufficient clinical improvement within 72 hours, this should be followed by endoscopic transluminal drainage or image-guided percutaneous catheter drainage (preferentially retroperitoneal to avoid bowel perforation and peritoneal leakage of pancreatic secretions). If needed these steps can be followed by respectively endoscopic transgastric necrosectomy or minimally invasive surgical necrosectomy following the route of initial drainage (5). The endoscopic approach leads to less pancreaticocutaneous fistula and a shorter hospital stay compared to the surgical approach.                                                                               

Especially, bowel complications in acute severe pancreatitis have received less attention in the literature, as priority is given to the correction of (secondary) organ failure. Therefore, these complications can often be missed during the disease and can lead to significant morbidity later on. 

A consistent and concerted approach, close cooperation as well as detailed communication between the intensivist, gastroenterologist skilled in endoscopy, surgeon, interventional radiologist and the microbiologist is required to optimize patient outcome (6).

Discussion

Patients with severe acute pancreatitis are amongst the most labor and resource intensive patients in critical care medicine. They are typically ill for an extended period because of the abovementioned complications and require numerous medical, surgical, radiological and nutritional interventions if they are to survive (4,6) The cognitive and emotional responses vary in patients with acute pancreatitis during hospitalization (7). Moreover, the patient, family and nursing staff often start questioning whether the patient will ever recover. Therefore, consultation of a psychologist for patient and family, and moral case deliberation with the team of health care providers may be extremely helpful.

Table 1. Complications of severe acute pancreatitis

Contributions

All authors equally contributed and approved all versions; Sjoerd van Bree wrote the first draft.

Conflicts of interest

The authors declare that there are no funding sources and no conflicts of interest

References

1.  Finkenstedt A, Jaber S, Joannidis M. Ten tips to manage severe acute pancreatitis in an intensive care unit. Intensive Care Med. 2023.

2.  van den Berg, Fons F., Boermeester, Marja A. Update on the management of acute pancreatitis. Current Opinion in Critical Care 29(2):p 145-151, April 2023.

3. Neyton, Lucile P. A., Zheng, Xiaozhong, Skouras, Christos, et al. Molecular Patterns in Acute Pancreatitis Reflect Generalizable Endotypes of the Host Response to Systemic Injury in Humans. Annals of Surgery 275(2):p e453-e462, February 2022.

4. e-Learning ACE course ‘Severe Acute Pancreatitis’. Third Edition, 2023. Academy of the European Society Intensive Care Medicine (ESICM).

5. Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med. 2021;385(15):1372-81.

6. Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet. 2020;396(10252):726-34.

7. Ma S, Yang X, He H, Gao Y, C et al. Psychological experience of inpatients with acute pancreatitis: a qualitative study. BMJ Open. 2022;12(6):e060107.