Management of Acute Pancreatitis
Publication Date: March 5, 2024
Last Updated: March 8, 2024
Diagnosis
- We suggest that early/at admission routine computed tomography (CT) not be performed for the purpose of determining severity in AP and should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first 48–72 hours after hospital admission and intravenous hydration.
Etiology
We suggest transabdominal ultrasound in patients with AP to evaluate for biliary pancreatitis and a repeat US if the initial examination is inconclusive. (C, VL )
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In patients with idiopathic AP (IAP), we recommend additional diagnostic evaluation with repeat abdominal ultrasound, MRI, and/or endoscopic ultrasound (EUS). (C, VL )
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- In the absence of gallstones and/or a significant history of alcohol use, serum triglyceride (TG) should be obtained and considered the etiology, preferably if greater than 1,000 mg/dL.
- In patients older than 40 years in whom an etiology is not established, a pancreatic tumor should be considered as a possible cause of AP.
- Following a second episode of AP with no identifiable cause, in patients fit for surgery, we suggest performing a cholecystectomy to reduce the risk of recurrent episodes of AP.
Initial Assessment and Risk Stratification
- Hemodynamic status and risk assessment should be performed to stratify patients into higher-risk and lower-risk categories to assist consideration of admission to a nonmonitored bed or monitored bed setting, including the intensive care setting.
- Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should preferably be admitted to a monitored bed setting.
- Scoring systems and imaging alone are not accurate in determining which patients with AP will develop moderately severe or severe AP.
- In patients with mild disease, clinicians should remain vigilant for the development of severe disease and organ failure during the initial 48 hours from admission.
- Risk factors of the development of severe disease (Table 4) include elevated blood urea nitrogen (BUN), hematocrit (HCT), the presence of obesity, comorbidities, and the presence of the SIRS.
Initial Management
We suggest moderately aggressive fluid resuscitation for patients with AP. Additional boluses will be needed if there is evidence of hypovolemia. (C, L )
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We suggest using lactated Ringer solution over normal saline for intravenous resuscitation in AP. (C, L )
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- While we suggest all patients with AP receive moderately aggressive intravenous hydration of isotonic crystalloid, caution is needed if a cardiovascular and/or renal comorbidity exists. Patients should be monitored for volume overload.
- Fluid resuscitation in patients with AP is likely more important early in the course of the disease (within the first 24 hours).
- Fluid volumes need to be reassessed at frequent intervals within 6 hours of presentation and for the next 24–48 hours with a goal to decrease the BUN.
ECRP
We suggest medical therapy over early (within the first 72 hours) ERCP in acute biliary pancreatitis without cholangitis. (C, L )
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- In patients with AP complicated by cholangitis, early ERCP within the first 24 hours has been shown to decrease morbidity and mortality.
- In the absence of cholangitis and/or jaundice, if a CBD stone is suspected, MRCP or EUS should be used to screen for the presence of CBD stones before the use of ERCP, and diagnostic ERCP should be avoided.
Preventing Post-ERCP Pancreatitis
We recommend rectal indomethacin to prevent post-ERCP pancreatitis (PEP) in individuals considered to be at high risk of PEP. (S, M )
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We suggest placement of a pancreatic duct stent in patients at high risk for PEP who are receiving rectal indomethacin. (C, L )
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Role of Antibiotics
We suggest against prophylactic antibiotics in patients with severe AP. (C, VL )
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We suggest against fine-needle aspiration (FNA) in patients with suspected infected pancreatic necrosis. (C, VL )
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- While antibiotics should not be used in patients with sterile necrosis, antibiotics are an important part of treatment in infected necrosis along with debridement/necrosectomy.
- In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis should be used largely to delay surgical, endoscopic, and radiologic drainage beyond 4 weeks. Some patients may avoid drainage altogether because the infection may completely resolve with antibiotics.
- Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not needed.
Nutrition
In patients with mild AP, we suggest early oral feeding (within 24–48 hours) as tolerated by the patient compared with the traditional nothing-by-mouth approach. (C, L )
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In patients with mild AP, we suggest initial oral feeding with low-fat solid diet rather than a stepwise liquid to solid approach. (C, L )
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- Enteral nutrition in patients with moderately severe or severe AP seems to prevent infectious complications.
- Parenteral nutrition should be avoided, unless the enteral route is not possible, not tolerated, or not meeting the caloric needs.
- Using a nasogastric rather than nasojejunal route for delivery of enteral feeding is preferred because of comparable safety and efficacy.
Role of Surgery
- Patients with mild acute biliary pancreatitis should undergo cholecystectomy early, preferably before discharge.
- Minimally invasive methods are preferred to open surgery for debridement and necrosectomy in stable patients with symptomatic pancreatic necrosis.
- We suggest delaying any intervention (surgical, radiological, and/or endoscopic) in stable patients with pancreatic necrosis, preferably 4 weeks, to allow for the wall of collection to mature.
Recommendation Grading
Overview
Title
Management of Acute Pancreatitis
Authoring Organization
American College of Gastroenterology
Publication Month/Year
March 5, 2024
Last Updated Month/Year
October 21, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline presents recommendations for the management of patients with acute pancreatitis (AP)
Target Patient Population
Patients with acute pancreatitis
Inclusion Criteria
Male, Female, Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D010195 - Pancreatitis, D019283 - Pancreatitis, Acute Necrotizing
Keywords
acute pancreatitis, diagnosis
Source Citation
Tenner, Scott MD, MPH, JD, FACG1; Vege, Santhi Swaroop MD, MACG2; Sheth, Sunil G. MD3; Sauer, Bryan MD, MSci, FACG4; Yang, Allison MD, MPH5; Conwell, Darwin L. MD, MSc, FACG6; Yadlapati, Rena H. MD, MHS, FACG7; Gardner, Timothy B. MD, FACG8. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. The American Journal of Gastroenterology 119(3):p 419-437, March 2024. | DOI: 10.14309/ajg.0000000000002645