American College of Gastroenterology Guidelines

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

2013 American College of Gastroenterology Guideline: Management of Acute Pancreatitis

Diagnosis

Recommendation	Evidence Level	Strength of Recommendation
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.	Moderate	Strong
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 48-72h after hospital admission.	Low	Strong

Determining Etiology

Recommendation	Evidence Level	Strength of Recommendation
Transabdominal ultrasound should be performed in all patients with acute pancreatitis	Low	Strong
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	Moderate	Conditional
In a patient older than 40 years, a pancreatic tumor should be considered as a possible cause of acute pancreatitis	Low	Conditional
Endoscopic investigation in patients with acute idiopathic pancreatitis should be limited, as the risks and benefits of investigation in these patients are unclear	Low	Conditional
Patients with idiopathic pancreatitis should be referred to centers of expertise	Low	Conditional
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	Low	Conditional

Initial Assessment and Risk Stratification

Recommendation	Evidence Level	Strength of Recommendation
Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed	Moderate	Strong
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	Moderate	Conditional
Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible	Low	Strong

Initial Management

Recommendation	Evidence Level	Strength of Recommendation
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	Moderate	Strong
In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed	Moderate	Conditional
Lactated Ringer's solution may be the preferred isotonic crystalloid replacement fluid	Moderate	Conditional
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	Moderate	Strong

Role of ERCP

Recommendation	Evidence Level	Strength of Recommendation
Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 h of admission	Moderate	Strong
ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction	Low	Strong
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	Low	Conditional
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	Moderate	Conditional

Role of Antibiotics

Recommendation	Evidence Level	Strength of Recommendation
Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia	High	Strong
Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended	Moderate	Strong
The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended	Moderate	Strong
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	Low	Strong
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	Low	Conditional
Routine administration of antifungal agents along with prophylactic or therapeutic antibiotics is not recommended	Low	Conditional

Nutrition in Acute Pancreatitis

Recommendation	Evidence Level	Strength of Recommendation
In mild AP, oral feedings can be started immediately if there is no nausea and vomiting, and abdominal pain has resolved	Moderate	Conditional
In mild AP, initiation of feeding with a low-fat solid diet appears as safe as a clear liquid diet	Moderate	Conditional
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	High	Strong
Nasogastric delivery and nasojejunal delivery of enteral feeding appear comparable in efficacy and safety	Moderate	Strong

Role of Surgery

Recommendation	Evidence Level	Strength of Recommendation
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	Moderate	Strong
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	Moderate	Strong
The presence of asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis do not warrant intervention, regardless of size, location, and/or extension	Moderate	Strong
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)	Low	Strong
In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy	Low	Strong