Last updated March 14, 2022

Management of Acute Pancreatitis

Recommendations 

Diagnosis 

The diagnosis of AP is most often established by the presence of two of the three following criteria:

(i) abdominal pain consistent with the disease
(ii) serum amylase and/or lipase greater than three times the upper limit of normal, and/or
(iii) characteristic findings from abdominal imaging.

(Strong  “We recommend”, Moderate)
317609
Contrast-enhanced computed tomographic (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first 48–72 h after hospital admission. (Strong  “We recommend”, Low)
317609

Etiology 

Transabdominal ultrasound should be performed in all patients with acute pancreatitis. (Strong  “We recommend”, Low)
317609
In the absence of gallstones and/or history of significant history of alcohol use, a serum triglyceride should be obtained and considered the etiology if >1,000 mg/dl. (Conditional (weak)  “We suggest”, Moderate)
317609
In a patient older than 40 years, a pancreatic tumor should be considered as a possible cause of acute pancreatitis. (Conditional (weak)  “We suggest”, Low)
317609
Endoscopic investigation in patients with acute idiopathic pancreatitis should be limited, as the risks and benefits of investigation in these patients are unclear. (Conditional (weak)  “We suggest”, Low)
317609
Patients with idiopathic pancreatitis should be referred to centers of expertise. (Conditional (weak)  “We suggest”, Low)
317609
Genetic testing may be considered in young patients (<30 years old) if no cause is evident and a family history of pancreatic disease is present. (Conditional (weak)  “We suggest”, Low)
317609

Initial assessment and risk stratification 

Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. (Strong  “We recommend”, Moderate)
317609
Risk assessment should be performed to stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting. (Conditional (weak)  “We suggest”, Moderate)
317609
Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible. (Strong  “We recommend”, Low)
317609

Initial management 

Aggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution should be provided to all patients, unless cardiovascular and/or renal comorbidites exist. Early aggressive intravenous hydration is most beneficial the first 12–24 h, and may have little benefit beyond. (Strong  “We recommend”, Moderate)
317609
In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed. (Conditional (weak)  “We suggest”, Moderate)
317609
Lactated Ringer’s solution may be the preferred isotonic crystalloid replacement fluid. (Conditional (weak)  “We suggest”, Moderate)
317609
Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next 24–48 h. The goal of aggressive hydration should be to decrease the blood urea nitrogen. (Strong  “We recommend”, Moderate)
317609

ERCP in acute pancreatitis 

Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 h of admission. (Strong  “We recommend”, Moderate)
317609
ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction. (Strong  “We recommend”, Low)
317609
In the absence of cholangitis and/or jaundice, MRCP or endoscopic ultrasound (EUS) rather than diagnostic ERCP should be used to screen for choledocholithiasis if highly suspected. (Conditional (weak)  “We suggest”, Low)
317609
Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to prevent severe post-ERCP pancreatitis in high-risk patients. (Conditional (weak)  “We suggest”, Moderate)
317609

The role of antibiotics in acute pancreatitis 

Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia. (Strong  “We recommend”, High)
317609
Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended. (Strong  “We recommend”, Moderate)
317609
The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended. (Strong  “We recommend”, Moderate)
317609
Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7–10 days of hospitalization. In these patients, either:

(i) initial CT-guided fine needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or
(ii) empiric use of antibiotics without CT FNA should be given.

(Strong  “We recommend”, Low)
317609
In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole, may be useful in delaying or sometimes totally avoiding intervention, thus decreasing morbidity and mortality. (Conditional (weak)  “We suggest”, Low)
317609
Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended. (Conditional (weak)  “We suggest”, Low)
317609

Nutrition in acute pancreatitis 

In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and abdominal pain has resolved. (Conditional (weak)  “We suggest”, Moderate)
317609
In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet. (Conditional (weak)  “We suggest”, Moderate)
317609
In severe AP, enteral nutrition is recommended to prevent infectious complications. Parenteral nutrition should be avoided unless the enteral route is not available, not tolerated, or not meeting caloric requirements. (Strong  “We recommend”, High)
317609
Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety. (Strong  “We recommend”, Moderate)
317609

The role of surgery in acute pancreatitis 

In patients with mild AP, found to have gallstones in the gallbladder, a cholecystectomy should be performed before discharge to prevent a recurrence of AP. (Strong  “We recommend”, Moderate)
317609
In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active infl ammation subsides and fluid collections resolve or stabilize. (Strong  “We recommend”, Moderate)
317609
The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension. (Strong  “We recommend”, Moderate)
317609
In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis). (Strong  “We recommend”, Low)
317609
In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy. (Strong  “We recommend”, Low)
317609

AP, acute pancreatitis; CT, computed tomography; ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangiopancreatography

Recommendation Grading

Overview

Title

Management of Acute Pancreatitis

Authoring Organization

Publication Month/Year

September 1, 2013

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

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D010195 - Pancreatitis, D019283 - Pancreatitis, Acute Necrotizing

Keywords

acute pancreatitis, diagnosis

Source Citation

American Journal of Gastroenterology: September 2013 - Volume 108 - Issue 9 - p 1400-1415
doi: 10.1038/ajg.2013.218