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Acute pancreatitis

Definition
Acute pancreatitis is a disease characterized by acute inflammation of the pancreas.
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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%).
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Epidemiology
The incidence of acute pancreatitis ranges from 13 to 45 cases per 100,000 person-years.
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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.
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Prognosis and risk of recurrence
Mortality associated with acute pancreatitis is approximately 1-5%, and the recurrence rate is approximately 20%.
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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 Diabetes Association (ADA 2024), the United European Gastroenterology (UEG/ESPEN 2023), the American Society for Gastrointestinal Endoscopy (ASGE 2023; 2015), the American Gastroenterological Association (AGA 2020; 2018), the World Society of Emergency Surgery (WSES 2019), 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).
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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
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2.Classification and risk stratification

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
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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.

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  • CRP

  • Additional laboratory tests

  • Abdominal imaging (ultrasound)

  • Abdominal imaging (CT/MRI)

  • MRCP/EUS

  • Evaluation for underlying cause

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

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  • Aspiration of peripancreatic fluid collections

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, WSES
Admit patients with acute pancreatitis and organ failures to an ICU whenever possible.
B
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

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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

7.Nonpharmacologic interventions

Nutrition support, oral feeding, AGA: offer a trial of oral nutrition immediately in patients with pancreatic necrosis without nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction.
B

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  • Nutrition support (enteral feeding)

  • Nutrition support (parenteral nutrition)

  • Brief intervention for alcohol misuse

8.Therapeutic procedures

Endoscopic retrograde cholangiopancreatography, indications, WSES: do not perform routine ERCP in patients with acute gallstone pancreatitis.
D
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  • ERCP (prevention of post-ERCP pancreatitis)

  • Percutaneous/endoscopic drainage (pancreatic necrosis)

  • Percutaneous/endoscopic drainage (gallstone pancreatitis)

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
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  • Cholecystectomy

  • Pancreatic necrosectomy

  • Distal pancreatectomy

  • Open abdomen

10.Specific circumstances

Patients with obesity
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

11.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

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  • Surveillance for pancreatic diabetes