This document provides guidelines for the initial management of acute pancreatitis in Indonesia. It recommends supportive care including aggressive fluid resuscitation, pain management, and nutritional support. For fluid resuscitation, lactated Ringer's solution is preferred over normal saline to reduce the risk of SIRS. Enteral nutrition is recommended over parenteral nutrition to prevent infectious complications in severe acute pancreatitis. Antibiotics are not recommended for sterile necrosis but are appropriate if necrosis becomes infected or if extrapancreatic infections develop.

2. KONSENSUS PENATALAKSANAAN PANKREATITIS AKUT DI
INDONESIA,
PERHIMPUNAN GASTROENTEROLOGI INDONESIA 2009

3. Gejala dan tanda
pankreatitis akut
Evaluasi Klinis Tingkat
Keparahan dan
Skala Prognostik
(BISAP, APACHE II, Ranson)
Pankreatitis ringan Pankreatitis berat
Tidak ada nekrosis
Terapi suportif:
•Cairan IV
•Analgesia
•Nutrisi
• Identifikasi/koreks
i etiologi
CT scan abdomen dengan
kontras
Ada nekrosis
Perburukan klinis/
Tidak ada perbaikan
Antibiotik, nutrisi enteral
(atau TPN)
Antibiotik selama 2 minggu,
nutrisi
Ada perbaikan
Tidak ada perbaikan
Perburukan klinis Aspirasi CT-guided untuk
pulasan Gram dan kultur
Nekrosis terinfeksi Nekrosis steril
Tindakan bedah
debridement
Perawatan suportif,
tindakan debridement
elektif

4. INITIAL
MANAGEMENT
supportive care :
1.fluid resuscitation
2.pain control
3.nutritional support.

5. fluid resuscitation
• aggressive hydration  5 to 10 mL/kg per
hour of isotonic crystalloid solution (eg,
normal saline or lactated Ringer's solution) to
all patients with acute pancreatitis, unless
cardiovascular, renal, or other related
comorbid factors preclude aggressive fluid
replacement.
• severe volume depletion that manifests
as hypotension and tachycardia 20
mL/kg of intravenous fluid given over
30 minutes followed by 3 mL/kg/hour
for 8 to 12 hours.

6. • fluid resuscitation with lactated Ringer's
solution may reduce the incidence of SIRS as
compared with normal saline
• In one small randomized trial of 40 patients,
patients who received lactated Ringer's had
significantly lower mean C-reactive protein
(CRP) levels compared with patients who
received normal saline (52 versus
104 mg/dL) and a significant reduction in systemic
inflammatory response syndrome (SIRS) after 24
hours (84 versus 0 percent).

7. While lactated Ringer’s has the theoretical
benefit of decreasing pancreatic
acidosis and reducing trypsin activity,
and has been shown to improve
outcomes like C-reactive protein (CRP)
levels and SIRS in some trials.
American Gastroenterological Association Institute Guideline on Initial
Management of
Acute Pancreatitis. 2018

8. goal-directed therapy for fluid
management
• reassessed  first 6 hours of admission
and for the next 24 to 48 hours.
• The rate of fluid resuscitation  adjusted
based on clinical assessment, hematocrit
and blood urea nitrogen (BUN) values

9. Adequate fluid replacement can be
assessed :
• by an improvement in vital signs : goal
heart rate <120 beats/minute, mean
arterial pressure between 65 to 85
mmHg
• urine output (>0.5 to 1 cc/kg/hour)
• reduction in hematocrit (goal 35 to
44 percent)
• BUN over 24 hours

10. 50
Medication Initial dose Frequency Usual Dose
Range
Morphine 2 mg 4 hrs 2-10 mg
Hydromorphone 0.2 mg 4 hrs 0.2-1.5 mg
Fentanyl 25 µg 4 hrs 25-100 µg
Pain Management for Acute Pancreatitis

11. Feeding vs No Feeding
The concept of “putting the pancreatic to rest”
Promotes healing, decreases pain, and reduces
secretion and leakage of pancreatic juices in
pancreas parenchyma and peripancreatic tissue
Ragins et al. Intrajejunal administration of an elemental
diet at neutral pH avoids pancreatic stimulation: studies in
dog and man American Journal of Surgery, vol. 126, no. 5,
pp. 606–614, 1973

12. NUTRITION
• In mild AP  started immediately, no nausea and
vomiting, and the abdominal pain has resolved,
feeding with a low-fat solid diet appears as
safe as a clear liquid diet
• In severe AP, enteral nutrition is recommended to
prevent infectious complications.
• Parenteral nutrition should be avoided, unless the
enteral route is not available, not tolerated, or not
meeting caloric requirements
• Nasogastric delivery and nasojejunal delivery of
enteral feeding appear comparable in efficacy and
safety

13. American Gastroenterological Association Institute Guideline on Initial
Management of
Acute Pancreatitis. 2018

14. Enteral vs Parenteral Nutrition
Enteral nutrition significantly reduced :
- mortality
- multiple organ failure
- systemic infections
- the need for operative
interventions compared to those
who received TPN
- length of hospital stay
Al-Omran et al. Cochrane Database of Systemic

15. American Gastroenterological Association Institute Guideline on Initial
Management of
Acute Pancreatitis. 2018

16. Traditionally recommended
prevent gastric contents passing
into the duodenum
inhibit the formation of intestinal
hormones that stimulate the
pancreas
Naso Gastric Tube: Suction

18. 58
Nasogastric Suction in Acute Pancreatitis

19. NGT vs NJT
Eatock FC et al. Am J Gastroenterol
2005;100:432-9

20. American Gastroenterological Association Institute Guideline on Initial
Management of
Acute Pancreatitis. 2018

21. THE ROLE OF ANTIBIOTICS IN ACUTE PANCREATITIS
• extrapancreatic infection, such as cholangitis,
catheter-acquired infections, bacteremia, urinary tract
infections, pneumonia
• Routine use of prophylactic antibiotics in patients with
severe AP is not recommended
• patients with sterile necrosis to prevent the
development of infected necrosis is not recommended

22. THE ROLE OF ANTIBIOTICS IN ACUTE
PANCREATITIS
• Infected necrosis should be considered in
patients with pancreatic or extrapancreatic
necrosis who fail to improve after 7 – 10 days of
hospitalization.
• antibiotics known to penetrate pancreatic necrosis,
such as carbapenems, quinolones, and
metronidazol
• Routine administration of antifungal agents
along with prophylactic or therapeutic antibiotics is
not recommended

23. 23
TINJAUAN PUSTAKA
Pada kasus ini diberikan antiobiotik golongan
sefalosporin yaitu ceftriaxone dan metronidazole pada
hari Ketiga perawatan, hal ini sudah sesuai dengan
guideline terbaru dari World Society of Emergency
Surgery (WSES) tahun 2019 dimana sefalosporin
generasi ketiga dan metronidazole memiliki penetrasi
menengah ke dalam jaringan pankreas dan efektif
melawan mikroorganisme pada sebagian besar infeksi
pankreas