Enteral feeding is the most appropriate management. Enteral feeding has been shown to reduce infectious complications, multiple organ failure, operative interventions, and mortality compared with feeding by total parenteral nutrition in patients with severe acute pancreatitis. This patient has moderately severe acute pancreatitis based on evidence of pancreatic necrosis and peripancreatic fluid collections. He also has several risk factors for severe disease based on the presence of three of four Systemic Inflammatory Response Syndrome (SIRS) criteria (pulse rate >90/min, leukocyte count >12,000/µL [12 × 10⁹/L], and respiration rate >20/min) and a blood urea nitrogen level greater than 23 mg/dL (8.2 mmol/L). Nasogastric and nasojejunal feeding appear to be comparable in safety and efficacy. The optimal time to start enteral nutrition remains under investigation, but it should commence no later than 72 hours after presentation. In mild acute pancreatitis, oral feeding may start when nausea and vomiting resolve.

Drainage of acute peripancreatic fluid collections (APFCs) is not appropriate at this time because most collections resolve without intervention. Asymptomatic APFCs require no treatment. Symptomatic APFCs can be treated medically with bowel rest, jejunal feeding, pancreatic enzymes, octreotide, and rarely pancreatic duct stenting. Rarely, APFCs persist beyond 4 weeks, when they become encapsulated and are labeled a pancreatic pseudocyst. Pseudocysts are amenable to drainage if clinically indicated based on persistent pain despite medical therapy, infected pseudocyst, or obstruction of the gastric outlet or biliary tract.

Endoscopic retrograde cholangiopancreatography in acute pancreatitis should be used only in the following clinical scenarios: (1) in a patient with ascending cholangitis (fever, right upper quadrant pain, and jaundice) concomitant with acute pancreatitis, or (2) in a patient with gallstone pancreatitis who is not improving clinically and has worsening liver chemistry test results. Patients with gallstone pancreatitis and no complications should have a cholecystectomy prior to discharge.