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    Management of Acute Pancreatitis (beta)

    Official guideline from the American College of Gastroenterology.

    Summary by Vineet Rolston, MD & Adam Goodman, MD
    Strength
    Strong recommendation
    Moderate recommendation
    Conditional recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis

    Diagnosis
    1. 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.
    2. CT/MRI should be limited to cases with unclear diagnosis or no clinical improvement within 48-72 hrs. CT and MRI are comparable in early assessment.
    Etiology
    1. Should perform ultrasound in all patients with acute pancreatitis.
    2. If no gallstones visualized and/or no history of alcohol use, should obtain serum triglyceride (may be considered etiology if >1,000 mg/dL).
    3. If age >40, underlying pancreatic tumor should be considered as a possible cause of acute pancreatitis.
    4. Should limit endoscopic investigation if acute idiopathic pancreatitis (unclear risk/benefits).
    5. In young patients (age <30) with family history and no other evident cause, may consider genetic testing.
    Assessment
    1. Should assess hemodynamic status immediately and begin resuscitation as needed.
    2. Should stratify patients into higher- and lower-risk categories to assist triage (validated risk tools include Atlanta Criteria or Revised Atlanta Criteria).
    3. Patients with organ failure should be admitted to ICU or intermediary care setting.

    Management

    Initial management
    1. 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).
    2. Rapid repletion (bolus) may be needed if hypotension and tachycardia are present.
    3. Lactated Ringer’s solution may be preferred replacement fluid.
    4. Should reassess fluid requirements within 6 hrs of admission and for the next 24-48 hrs (goal = decrease BUN and hematocrit, and maintain creatinine.
    ERCP
    1. Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 hours.
    2. ERCP not needed in gallstone pancreatitis without laboratory/clinical evidence of ongoing biliary obstruction.
    3. If suspicion of choledocholithiasis is high, and there is no cholangitis or jaundice, should use MRCP or EUS over ERCP.
    4. In patients at high risk for post-ERCP pancreatitis, should use pancreatic duct stents and/or rectal NSAID.
    Antibiotics
    1. Should give antibiotics if extrapancreatic infections e.g. cholangitis, bacteremia, UTI, pneumonia.
    2. Prophylactic antibiotics with severe acute pancreatitis not recommended.
    3. Antibiotics in patients with sterile necrosis to prevent infected necrosis not recommended.
    4. 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.
    5. In infected necrosis, penetrating antibiotics e.g. carbapenems, quinolones, metronidazole, may delay/avoid intervention (and thus decrease morbidity/mortality).
    6. Routine use of antifungal agents not recommended.
    Nutrition
    1. In mild acute pancreatitis, oral feeding can start immediately if pain resolved and no nausea/vomiting.
    2. In mild acute pancreatitis, low-fat solid diet appears as safe as clear liquids.
    3. 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.
    4. Nasogastric and nasojejunal delivery of enteral feeding appear comparable.
    Surgery
    1. In patients with mild acute pancreatitis and gallstones, should perform cholecystectomy before discharge to prevent recurrence.
    2. In necrotizing biliary acute pancreatitis, defer cholecystectomy until active inflammation subsides and fluid collections resolve/stabilize.
    3. Asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant investigation regardless of size, location, or extension.
    4. 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).
    5. If symptomatic infected necrosis, minimally invasive methods such as cyst gastrostomy/duodenostomy are preferred to open necrosectomy.
    What do the icons mean?  
    Research PaperTenner S, Baillie J, Dewitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400-15.