Acute necrotising pancreatitis – early management in the district general hospital and tertiary hepato-pancreatico-biliary unit

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.