What are the guideline sources, guidelines and references for Acute pancreatitis ?
Guideline sources The following summarized guidelines for the evaluation and management of acute pancreatitis are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2023; 2015), the World Society of Emergency Surgery (WSES 2019), the American Gastroenterological Association (AGA 2018), the Eastern Association for the Surgery of Trauma (EAST 2017), the Canadian Best Practice in General Surgery Group (BPIGS 2016), the American Society for Clinical Pathology (ASCP 2016), the European Association for the Study of the Liver (EASL 2016), and the American College of Gastroenterology (ACG 2013). 1 2 3 4 5 6 8 9 10 11 12 13 14 15 Definition Acute pancreatitis is a disease characterized by acute inflammation of the pancreas. 11 Epidemiology https://web.pathway.md/diseases/recaG49TSo0aGldQK 1/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Acute pancreatitis is most frequently due to gallstones (40%) and alcohol (30%). Other minor causes include ERCP (5-10%), surgical complications (5-10%), drugs (< 5%), hypertriglyceridemia (2-5%), trauma (< 1%), infection (< 1%) and autoimmunity (< 1%). 13 Pathophysiology The incidence of acute pancreatitis ranges from 13 to 45 cases per 100,000 person-years. 12 Disease course In patients with acute pancreatitis, localized tissue damage causes activation of pro-inflammatory cytokines, leading to a systemic inflammatory response that can progress to multiple organ failure and early mortality. The compensatory release of anti-inflammatory mediators plays a role in causing increased susceptibility to septic complications, such as infected pancreatic necrosis, and contributes to late mortality. 14 Prognosis and risk of recurrence Mortality associated with acute pancreatitis is approximately 1-5%, and the recurrence rate is approximately 20%. 15 Calculator Calculator Calculator BISAP score for mortality in pan CT severity index for acute panc Determina Guidelines 1. Screening and diagnosis Diagnostic criteria: As per EASL 2016 guidelines, diagnose acute biliary pancreatitis in patients with upper abdominal pain, altered pancreatic and liver biochemical tests, and gallbladder and/or common bile duct stones. B As per ACG 2013 guidelines, diagnose acute pancreatitis in patients presenting with 2 of the following 3 criteria: abdominal pain consistent with the disease serum amylase and/or lipase > 3 times the ULN characteristic findings on abdominal imaging. B 2. Classification and risk stratification https://web.pathway.md/diseases/recaG49TSo0aGldQK 2/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Risk assessment: As per WSES 2019 guidelines, consider using the new classification systems, the determinant- based and revised Atlanta classifications, for the diagnosis and assessment of severity of acute pancreatitis. B Show 3 more As per BPIGS 2016 guidelines: Calculate APACHE II scores on admission and daily thereafter for the first 72 hours after admission. B Diagnose severe acute pancreatitis in patients meeting any of the following criteria: CRP 14,286 nmol/L (150 mg/dL) at baseline or in the first 72 hours APACHE II score 8 at baseline or in the first 72 hours signs of persistent organ failure for > 48 hours despite adequate IV fluid resuscitation. B As per ACG 2013 guidelines: Categorize patients into higher- and lower-risk categories to assist triage in situations such as admission to an intensive care setting. B Admit patients with organ failure to the ICU or intermediary care setting. B 3. Diagnostic investigations Serum lipase and amylase: As per WSES 2019 guidelines, use 3 times the upper limit as the cut-off value of serum amylase and lipase. As per ASCP 2016 guidelines, obtain serum lipase rather than amylase in patients with suspected acute pancreatitis. B As per BPIGS 2016 guidelines, obtain serum lipase in all patients with suspected acute pancreatitis. B C-reactive protein: As per WSES 2019 guidelines, consider using CRP level 150 mg/L at the third day as a prognostic factor for severe acute pancreatitis. B As per BPIGS 2016 guidelines, obtain CRP at admission and daily for the first 72 hours after admission. B Additional laboratory tests: Recognize that: hematocrit > 44% represents an independent risk factor of pancreatic necrosis B urea > 20 mg/dL represents an independent predictor of mortality B procalcitonin is the most sensitive laboratory test for detection of pancreatic infection, and low serum values are strong negative predictors of infected pancreatic necrosis. B Abdominal imaging, ultrasound: As per WSES 2019 guidelines: https://web.pathway.md/diseases/recaG49TSo0aGldQK 3/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Obtain abdominal ultrasound on admission to determine the possible biliary etiology of acute pancreatitis. B Obtain two ultrasound examinations to rule out biliary etiology in patients with idiopathic pancreatitis to prevent recurrent pancreatitis. B As per BPIGS 2016 guidelines, obtain abdominal ultrasound in all patients at baseline to evaluate the biliary tract and the presence of gallstones and/or a stone in the common bile duct. A As per ACG 2013 guidelines, obtain abdominal ultrasound in all patients with acute pancreatitis. B Abdominal imaging, computed tomography/magnetic resonance imaging: As per WSES 2019 guidelines: Obtain CT to provide good evidence of the presence or absence of pancreatitis, when doubt exists. B Obtain contrast-enhanced CT or MRI in all patients with severe acute pancreatitis. Obtain the first contrast-enhanced CT optimally 72-96 hours after onset of symptoms. B As per BPIGS 2016 guidelines, obtain abdominal CT in patients with: broad differential diagnosis that includes acute pancreatitis suspected local complication. B As per ACG 2013 guidelines, reserve contrast-enhanced CT and MRI of the pancreas for patients with unclear diagnosis or failing to improve clinically within the first 48-72 hours after hospital admission. B Magnetic resonance cholangiopancreatography/endoscopic ultrasound: As per WSES 2019 guidelines: Consider obtaining MRCP and/or EUS to screen for occult common bile duct stones in patients with acute pancreatitis of unknown etiology. B Obtain MRCP and/or EUS, if needed, to prevent recurrent pancreatitis in patients with idiopathic pancreatitis. B As per BPIGS 2016 guidelines, obtain MRCP only in patients with elevation of liver enzymes if the common bile duct is either not visualized adequately or is found to be normal on ultrasound. A As per ACG 2013 guidelines, obtain MRCP or EUS instead of diagnostic ERCP to screen for choledocholithiasis, if highly suspected, in patients with acute pancreatitis in the absence of cholangitis and jaundice. B Evaluation for underlying cause: As per WSES 2019 guidelines, obtain serum triglyceride and calcium levels in patients with acute pancreatitis in the absence of gallstones or significant history of alcohol use. Recognize that serum triglyceride levels > 11.3 mmol/L (1,000 mg/dL) indicate it as the etiology. B As per ACG 2013 guidelines, obtain serum triglycerides in patients with suspected acute pancreatitis in the absence of gallstones and/or significant history of alcohol use. Suspect that https://web.pathway.md/diseases/recaG49TSo0aGldQK 4/13 6/23/23, 2:02 AM Acute pancreatitis Pathway hypertriglyceridemia is the cause of pancreatitis at triglyceride levels > 1,000 mg/dL. B Show 2 more 4. Diagnostic procedures Endoscopic retrograde cholangiopancreatography: As per AGA 2018 guidelines, avoid performing urgent ERCP routinely in patients with acute biliary pancreatitis and no cholangitis. D As per ASGE 2015 guidelines, perform ERCP in patients with acute biliary pancreatitis with concomitant cholangitis or biliary obstruction. A Show 2 more As per ACG 2013 guidelines, limit the use of endoscopic investigations in patients with acute idiopathic pancreatitis because of unclear risks and benefits. B Aspiration of peripancreatic fluid collections: As per WSES 2019 guidelines, consider performing CT guided FNA for Gram stain and culture to confirm an infected severe acute pancreatitis and drive antibiotic therapy, but recognize that it is no longer in routine use. B As per BPIGS 2016 guidelines, observe patients with acute peripancreatic fluid collections in the absence of radiological or clinical suspicion of infection, and avoid image-guided FNA owing to the risk of introducing infection into a sterile collection. B As per ACG 2013 guidelines, explore the possibility of infected necrosis in patients with pancreatic or extrapancreatic necrosis deteriorating or failing to improve after 7-10 days of hospitalization. Obtain initial CT-guided FNA for Gram stain and culture to guide use of appropriate antibiotics. Alternatively, start empirical antibiotics without CT-guided FNA. B 5. Respiratory support Mechanical ventilation: Perform mechanical ventilation if oxygen supply, even with high flow nasal oxygen, or CPAP are ineffective in correcting tachypnea and dyspnea in patients with acute pancreatitis. B Use either noninvasive or invasive techniques for mechanical ventilation. Use invasive ventilation when bronchial secretions clearance start to be ineffective and/or the patient is tiring or predicted to tire. Follow lung-protective strategies when invasive ventilation is needed. B 6. Medical management Setting of care, intensive care unit: As per WSES 2019 guidelines: Admit patients with acute pancreatitis and organ failures to an ICU whenever possible. B https://web.pathway.md/diseases/recaG49TSo0aGldQK 5/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Obtain continuous monitoring of vital signs in high dependency care units if organ dysfunction occurs in patients with acute pancreatitis. Admit patients with persistent organ dysfunction or organ failure despite adequate fluid resuscitation to an ICU. B As per BPIGS 2016 guidelines, evaluate the need for transfer to a monitored unit in patients with severe acute pancreatitis, as evidenced by: APACHE II score > 8 CRP > 150 mg/dL presence of or evolving organ dysfunction need for aggressive, ongoing fluid resuscitation. B Setting of care, tertiary care: As per BPIGS 2016 guidelines, refer high-risk patients (extensive necrotizing pancreatitis, lack of clinical improvement) to institutions that have on-site or access to therapeutic endoscopy, interventional radiology, surgeons and intensivists with expertise in dealing with severe acute pancreatitis. B As per ACG 2013 guidelines, refer patients with idiopathic pancreatitis to centers of expertise. B Supportive care, general principles: As per WSES 2019 guidelines, be cautious not to over-resuscitate patients with early severe acute pancreatitis and consider obtaining regular measurements of intra-abdominal pressure. B Show 2 more As per BPIGS 2016 guidelines, provide supportive care including resuscitation with isotonic IV fluids (Ringer's lactate), pain control, and mobilization as the mainstay of treatment for patients with mild acute pancreatitis. B As per ACG 2013 guidelines, assess hemodynamic status immediately upon presentation and begin resuscitative measures as needed. B Supportive care, fluid therapy: As per WSES 2019 guidelines: Initiate early fluid resuscitation preferably with isotonic crystalloids in patients with severe acute pancreatitis to optimize tissue perfusion targets, without waiting for hemodynamic worsening. B Obtain frequent reassessment of the hemodynamic status to guide fluid administration, since fluid overload has detrimental effects. B Updated evidence: WATERFALL In adult patients who presented to the emergency department with acute pancreatitis, aggressive fluid resuscitation was not superior to moderate fluid resuscitation with respect to the development of moderately severe or severe pancreatitis. https://web.pathway.md/diseases/recaG49TSo0aGldQK 6/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Enrique de-Madaria et al. N Engl J Med. 2022 Sep 15. As per AGA 2018 guidelines: Consider using goal-directed therapy for fluid management in patients with acute pancreatitis. C Consider avoiding the use of hydroxyethyl starch fluids in patients with acute pancreatitis. D As per ACG 2013 guidelines, provide aggressive IV hydration, defined as 250-500 mL/hour of isotonic crystalloid solution, in all patients in the first 12-24 hours, unless cardiovascular and/or renal comorbidities exist. B Show 3 more Supportive care (pain management): insufficient evidence to restrict any pain medication in patients with acute pancreatitis. I Show 3 more Antibiotic therapy: As per AGA 2018 guidelines, consider avoiding the use of prophylactic antibiotics in patients with predicted severe acute pancreatitis and necrotizing pancreatitis. D As per BPIGS 2016 guidelines, avoid using routine prophylactic antibiotics in patients with acute pancreatitis. D Show 3 more As per ACG 2013 guidelines, administer antibiotics for an extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, UTIs, and pneumonia. A Show 4 more Specific pharmacotherapy: do not use any specific pharmacological therapy except for organ support and nutrition in patients with acute pancreatitis. D Management of pancreatic pseudocysts: As per BPIGS 2016 guidelines: Manage asymptomatic pancreatic pseudocysts nonoperatively. B Perform intervention for pseudocysts that are symptomatic, infected, or increasing in size on serial imaging. B 7. Nonpharmacologic interventions Nutrition support: As per WSES 2019 guidelines, provide enteral nutrition to prevent gut failure and infectious complications in patients with severe acute pancreatitis. A Show 2 more As per AGA 2018 guidelines, start oral feeding within 24 hours as tolerated in patients with acute pancreatitis, rather than keeping the patient NPO. B As per AGA 2018 guidelines: https://web.pathway.md/diseases/recaG49TSo0aGldQK 7/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Provide enteral rather than parenteral nutrition in patients with acute pancreatitis unable to feed PO. B Consider using either nasogastric or nasoenteral route in patients with predicted severe or necrotizing pancreatitis requiring enteral tube feeding. C As per BPIGS 2016 guidelines: Allow a regular diet on admission in patients with mild acute pancreatitis. A Allow patients to self-advance their diet from withholding oral food and liquid to a regular diet as tolerated if they initially are unable to tolerate an oral diet owing to abdominal pain, nausea, vomiting, or ileus. A As per ACG 2013 guidelines, consider starting oral feeds immediately in patients with mild acute pancreatitis if there is no nausea and vomiting, and abdominal pain has resolved. C Show 3 more Brief intervention for alcohol misuse: implement a brief alcohol intervention during admission in patients with acute alcoholic pancreatitis. B 8. Therapeutic procedures Endoscopic retrograde cholangiopancreatography, indications: As per WSES 2019 guidelines, do not perform routine ERCP in patients with acute gallstone pancreatitis. D Show 2 more As per BPIGS 2016 guidelines, perform ERCP within 24-48 hours in patients with acute gallstone pancreatitis associated with bile duct obstruction or cholangitis. B As per ACG 2013 guidelines: Perform ERCP within 24 hours of admission in patients with acute pancreatitis and concurrent acute cholangitis. B Avoid performing ERCP in patients with gallstone pancreatitis in the absence of laboratory or clinical evidence of ongoing biliary obstruction. D Percutaneous/endoscopic drainage: As per WSES 2019 guidelines: Perform percutaneous or endoscopic drainage in patients with clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis: 4 weeks after the onset of the disease: ongoing organ failure without signs of infected necrosis; ongoing gastric outlet, biliary, or intestinal obstruction due to a large walled off necrotic collection; disconnected duct syndrome; symptomatic or growing pseudocyst 8 weeks after the onset of the disease: ongoing pain and/or discomfort. B Perform percutaneous drainage as first-line treatment (step-up approach) in patients with infected pancreatic necrosis, as it delays the surgical treatment to a more favorable time or even results in complete resolution of infection in 25-60% of patients. A https://web.pathway.md/diseases/recaG49TSo0aGldQK 8/13 6/23/23, 2:02 AM Acute pancreatitis Pathway As per BPIGS 2016 guidelines, consider performing percutaneous transhepatic gallbladder drainage in unstable patients with severe acute gallstone pancreatitis and associated bile duct obstruction or cholangitis, if ERCP is not safely feasible. B Endoscopic retrograde cholangiopancreatography, prevention of post-ERCP pancreatitis: As per ASGE 2023 guidelines, administer periprocedural rectal NSAIDs for the prevention of post-ERCP pancreatitis in unselected and high-risk patients undergoing ERCP. B Show 4 more As per ACG 2013 guidelines, perform pancreatic duct stenting and/or administer postprocedural rectal NSAID suppositories to prevent severe pancreatitis after ERCP in high-risk patients. B 9. Surgical interventions General principles: As per WSES 2019 guidelines, perform surgical intervention as a continuum in a step-up approach after percutaneous/endoscopic procedure with the same indications, or in patients with any of the following: abdominal compartment syndrome acute ongoing bleeding if endovascular approach is unsuccessful bowel ischemia or acute necrotizing cholecystitis during acute pancreatitis bowel fistula extending into a peripancreatic collection. B Show 3 more As per ACG 2013 guidelines, delay surgical, radiologic and/or endoscopic drainage preferably for > 4 weeks in stable patients with infected pancreatic necrosis to allow liquefaction of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis). B Cholecystectomy: As per WSES 2019 guidelines, perform laparoscopic cholecystectomy during the index admission in patients with mild acute gallstone pancreatitis. A Show 2 more As per AGA 2018 guidelines, perform cholecystectomy in patients with acute biliary pancreatitis during the initial admission rather than after discharge. B As per BPIGS 2016 guidelines: Perform cholecystectomy during the index admission in patients with mild acute pancreatitis. B Delay cholecystectomy until clinical resolution in patients with severe acute pancreatitis. B As per ACG 2013 guidelines: Perform cholecystectomy in patients with mild acute pancreatitis prior to discharge, if they have gallstones in the gallbladder. B Defer cholecystectomy in patients with necrotizing biliary acute pancreatitis until active inflammation subsides and fluid collections resolve or stabilize. B https://web.pathway.md/diseases/recaG49TSo0aGldQK 9/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Pancreatic necrosectomy: As per WSES 2019 guidelines: Recognize that minimally invasive surgical strategies, such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement, result in less postoperative new- onset organ failure but require more interventions. B Consider performing single-stage surgical transgastric necrosectomy as an option in selected patients with walled-off necrosis or with disconnected pancreatic duct. C As per EAST 2017 guidelines, delay pancreatic necrosectomy until at least day 12 in adult patients with pancreatic necrosis. B Show 2 more As per ACG 2013 guidelines, perform minimally invasive methods of necrosectomy rather than open necrosectomy in symptomatic patients with infected pancreatic necrosis. B Landmark trials: PANTER In patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue, a step-up approach to management of pancreatic necrosis were superior to primary open necrosectomy with respect to death or major complications. van Santvoort HC et al. N Engl J Med. 2010 Apr 22. Open abdomen: consider performing surgical decompression and leaving the abdomen open for the treatment of abdominal compartment syndrome in patients with severe acute pancreatitis unresponsive to conservative management of intra-abdominal hypertension/abdominal compartment syndrome. C Show 7 more 10. Follow-up and surveillance Follow-up imaging: As per WSES 2019 guidelines: Obtain follow-up contrast-enhanced CT after 7-10 days from the initial CT in patients with severe acute pancreatitis (CT severity index 3). B Obtain additional contrast-enhanced CT only if clinical status deteriorates or fails to show continued improvement, or when invasive intervention is considered. B As per BPIGS 2016 guidelines, obtain follow-up abdominal CT as dictated by clinical assessment, rather than at set intervals. B Likelihood Ratios https://web.pathway.md/diseases/recaG49TSo0aGldQK 10/13 6/23/23, 2:02 AM Acute pancreatitis Pathway Pertinent positives The following findings increase the probability of acute pancreatitis in adults. 1 1 1 Finding LR+ Value Increased serum lipase (> 3x ULN) 99 Presence of findings of acute pancreatitis 52 Presence of findings of acute pancreatitis 36 Increased serum ALT (> 150 units/L) 12 Show 2 more Pertinent negatives The following findings decrease the probability of acute pancreatitis in adults. 1 1 1 Finding LR- Value serum lipase not increased ( 3x ULN) 0.01 serum immunoreactive trypsinogen not increased 0.04 serum amylase not increased ( 300 units/mL) 0.06 Absence of findings of acute pancreatitis 0.29 Show 2 more References 1. Tenner S, Baillie J, DeWitt J et al. 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