Management of Acute Pancreatitis(beta)
Official guideline from the American College of Gastroenterology.
summary by Vineet Rolston, MD Adam Goodman, MD
Diagnose with any 2 of the following: (i) characteristic abdominal pain, (ii) amylase and/or lipase >3x upper limit of normal, (iii) characteristic imaging findings.
Should perform ultrasound in all patients with acute pancreatitis.
If no gallstones visualized and/or no history of alcohol use, should obtain serum triglyceride (may be considered etiology if >1,000 mg/dL).
If age >40, underlying pancreatic tumor should be considered as a possible cause of acute pancreatitis.
Should limit endoscopic investigation if acute idiopathic pancreatitis (unclear risk/benefits).
Should assess hemodynamic status immediately and begin resuscitation as needed.
Should stratify patients into higher- and lower-risk categories to assist triage (validated risk tools include Atlanta Criteria or Revised Atlanta Criteria).
Aggressive hydration (250-500 mL/hr isotonic crystalloid) should be used unless there are cardiac and/or renal comorbidities, particularly in the first 12-24 hrs (and may have little benefit beyond).
Rapid repletion (bolus) may be needed if hypotension and tachycardia are present.
Lactated Ringer’s solution may be preferred replacement fluid.
Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 hours.
ERCP not needed in gallstone pancreatitis without laboratory/clinical evidence of ongoing biliary obstruction.
If suspicion of choledocholithiasis is high, and there is no cholangitis or jaundice, should use MRCP or EUS over ERCP.
Should give antibiotics if extrapancreatic infections e.g. cholangitis, bacteremia, UTI, pneumonia.
Prophylactic antibiotics with severe acute pancreatitis not recommended.
Antibiotics in patients with sterile necrosis to prevent infected necrosis not recommended.
Should consider infected necrosis in patients who deteriorate or fail to improve in 7-10 days. Should use either (i) CT-guided FNA for gram stain culture to guide antibiotics or (ii) empiric antibiotics without FNA.
In infected necrosis, penetrating antibiotics e.g. carbapenems, quinolones, metronidazole, may delay/avoid intervention (and thus decrease morbidity/mortality).
In mild acute pancreatitis, oral feeding can start immediately if pain resolved and no nausea/vomiting.
In mild acute pancreatitis, low-fat solid diet appears as safe as clear liquids.
In severe acute pancreatitis, enteral nutrition is recommended to prevent infection. Should avoid parenteral nutrition unless enteral route not available, not tolerable, or caloric requirements not met.
In patients with mild acute pancreatitis and gallstones, should perform cholecystectomy before discharge to prevent recurrence.
In necrotizing biliary acute pancreatitis, defer cholecystectomy until active inflammation subsides and fluid collections resolve/stabilize.
Asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant investigation regardless of size, location, or extension.
In stable patients with infected necrosis, surgical, radiologic and/or endoscopic drainage should be delayed >4 weeks for liquefaction and development of fibrous wall (walled-off necrosis).
How strong is the ACG's recommendation?