Best Fluid Resuscitation Strategy in Acute Pancreatitis

Acute pancreatitis (AP) is a prevalent and potentially life-threatening condition with rising global incidence and substantial morbidity, mortality, and healthcare costs. Early management centers on supportive care, with fluid resuscitation being a pivotal intervention during the acute phase. However, recent evidence has questioned the efficacy of aggressive fluid administration, previously thought to improve outcomes by mitigating hypovolemia and complications. This review synthesizes current data regarding fluid resuscitation strategies in AP, emphasizing the variability in individual fluid needs, the central roles of endothelial and glycocalyx integrity, and the risks of both under- and over-hydration. Notably, findings from large randomized controlled trials, including the influential WATERFALL study, demonstrate that aggressive fluid resuscitation increases the incidence of fluid overload without improving clinical outcomes compared to moderate strategies. Subsequent meta-analyses and guideline updates now endorse a moderate fluid resuscitation approach, as reflected in the 2024 American College of Gastroenterology recommendations. The review concludes that while fluid therapy remains the cornerstone of early AP management, a shift toward tailored, moderate fluid administration is warranted to optimize outcomes and minimize harm. Continued research is essential to refine individualized resuscitation protocols, with particular attention to biomarkers of endothelial dysfunction and fluid requirements.