EBQ:Pancreatitis guidelines

Diagnosis

• The diagnosis of acute pancreatitis (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 recommendation, moderate quality of evidence).

• 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 recommendation, low quality of evidence).

Etiology

• Transabdominal ultrasound should be performed in all patients with acute pancreatitis (strong recommendation, low quality of evidence)

• 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 recommendation, moderate quality of evidence).

• In a patient older than 40 years, a pancreatic tumor should be considered as a possible cause of acute pancreatitis (conditional recommendation, low quality of evidence).

• Endoscopic investigation in patients with acute idiopathic pancreatitis should be limited, as the risks and benefits of investigation in these patients are unclear (conditional recommendation, low quality of evidence).

• Patients with idiopathic pancreatitis should be referred to centers of expertise (conditional recommendation, low quality of evidence)

• 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 recommendation, low quality of evidence).

Initial Assessment

• Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible (strong recommendation, low quality of evidence).

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 co-morbidities exist. Early aggressive intravenous hydration is most beneficial the first 12 – 24 h, and may have little benefit beyond (strong recommendation, moderate quality of evidence).

• In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed (conditional recommendation, moderate quality of evidence).

• Lactated Ringer’s solution may be the preferred isotonic crystalloid replacement fluid (conditional recommendation, moderate quality of evidence).

• 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 recommendation, moderate quality of evidence).

• Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 h of admission (strong recommendation, moderate quality of evidence).

• ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction (strong recommendation, low quality of evidence).

• 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 recommendation, low quality of evidence).

The Role of Antibiotics

• Antibiotics should be given for an extra-pancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia (strong recommendation, high quality of evidence).

• Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended (strong recommendation, moderate quality of evidence).

• The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended (strong recommendation, moderate quality of evidence).

• Infected necrosis should be considered in patients with pancreatic or extra-pancreatic 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 recommendation, low quality of evidence).

• 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 recommendation, low quality of evidence).

• Routine administration of anti-fungal agents along with prophylactic or therapeutic antibiotics is not recommended (conditional recommendation, low quality of evidence).

Nutrition

• In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and abdominal pain has resolved (conditional recommendations, moderate quality of evidence).

• In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet (conditional recommendations, moderate quality of evidence).

• 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 recommendation, high quality of evidence).

Surgery

• 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 recommendation, moderate quality of evidence).

• In a patient with necrotizing biliary AP, in order to prevent infection, cholecystectomy is to be deferred until active inflammation subsides and fluid collections resolve or stabilize (strong recommendation, moderate quality of evidence).

• The presence of asymptomatic pseudocysts and pancreatic and/or extra-pancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension (strong recommendation, moderate quality of evidence).

• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed preferably for more than 4 weeks to allow liquification of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis) (strong recommendation, low quality of evidence).

See Also

Pancreatitis

References

• American College of Gastroenterology Guideline: Management of Acute Pancreatitis. July, 2013.

Authors

Alonzo Woodfield, Ross Donaldson, Daniel Ostermayer