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Table of contents

Acute pancreatitis

What's new

Updated 2024 ACG guidelines for the diagnosis and management of acute pancreatitis.

Background

Overview

Definition
Acute pancreatitis is a disease characterized by acute inflammation of the pancreas.
1
Pathophysiology
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%).
2
Epidemiology
The incidence of acute pancreatitis ranges from 13 to 45 cases per 100,000 person-years.
3
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.
4
Prognosis and risk of recurrence
Mortality associated with acute pancreatitis is approximately 1-5%, and the recurrence rate is approximately 20%.
5

Guidelines

Key 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 College of Gastroenterology (ACG 2024), the American Diabetes Association (ADA 2024), the American Society for Gastrointestinal Endoscopy (ASGE 2023,2015), the United European Gastroenterology (UEG/ESPEN 2023), the American Gastroenterological Association (AGA 2020,2018), the World Society of Emergency ...
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Screening and diagnosis

Diagnostic criteria: as per ACG 2024 guidelines, diagnose acute pancreatitis in the presence of ≥ 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.
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Classification and risk stratification

Risk assessment: as per ACG 2024 guidelines, obtain hemodynamic status and risk assessment 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.
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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.

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  • CRP

  • Additional laboratory tests

  • Abdominal imaging (ultrasound)

  • Abdominal imaging (CT/MRI)

  • MRCP/EUS

  • Evaluation for underlying cause

Diagnostic procedures

ERCP: as per AGA 2018 guidelines, avoid performing urgent ERCP routinely in patients with acute biliary pancreatitis and no cholangitis.
D

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  • Aspiration of peripancreatic fluid collections

Respiratory support

Mechanical ventilation
As per WSES 2019 guidelines:
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

Medical management

Setting of care, ICU: as per ACG 2024 guidelines, admit patients with organ failure and/or systemic inflammatory response syndrome preferably to a monitored bed setting.

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  • Setting of care (tertiary care)

  • Supportive care (general principles)

  • Supportive care (fluid therapy)

  • Supportive care (pain management)

  • Antibiotic therapy (prophylactic)

  • Antibiotic therapy (therapeutic)

  • Antifungal therapy

  • Specific pharmacotherapy

  • Management of pancreatic pseudocysts

Nonpharmacologic interventions

Nutrition support, oral feeding
As per ACG 2024 guidelines:
Consider initiating early oral feeding (within 24-48 hours) as tolerated by the patient over the traditional NPO approach in patients with mild acute pancreatitis.
C
Consider using low-fat solid diet over a stepwise liquid to solid approach for initial oral feeding in patients with mild acute pancreatitis.
C

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  • Nutrition support (enteral feeding)

  • Nutrition support (parenteral nutrition)

  • Brief intervention for alcohol misuse

Therapeutic procedures

ERCP, indications
As per ACG 2024 guidelines:
Perform early ERCP within the first 24 hours of admission to decrease morbidity and mortality in patients with acute pancreatitis complicated by cholangitis.
Consider initiating medical therapy over early (within the first 72 hours) ERCP in patients with acute biliary pancreatitis without cholangitis.
C

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  • ERCP (prevention of post-ERCP pancreatitis)

  • Percutaneous/endoscopic drainage (pancreatic necrosis)

  • Percutaneous/endoscopic drainage (gallstone pancreatitis)

Surgical interventions

General principles: as per ACG 2024 guidelines, consider 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.

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  • Cholecystectomy

  • Pancreatic necrosectomy

  • Distal pancreatectomy

  • Open abdomen

Specific circumstances

Patients with obesity
As per ESPEN/UEG 2023 guidelines:
Do not offer special nutrition care in patients with acute pancreatitis and obesity compared to lean patients with acute pancreatitis.
D
Consider offering an isocaloric high-protein diet (> 1.3 g/kg adjusted body weight/day) in the acute phase of severe acute pancreatitis in patients with obesity. Guide energy and protein intake by indirect calorimetry. Do not offer particular nutritional treatment beyond the recommendations for patients with obesity in general, apart from the acute phase of acute pancreatitis.
C

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
CT severity index for acute pancreatitis
CT findings
Normal pancreas
Focal or diffuse pancreatic enlargement
Pancreatic inflammation and/or peripancreatic fat
Single peripancreatic fluid collection
≥ 2 fluid collections and/or retroperitoneal air
Extent of necrosis
No necrosis
Necrosis of one-third of pancreas
Necrosis of half of pancreas
Necrosis of 50% of pancreas
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