On July 30, the American Journal of Gastroenterology (Am J Gastroenterol) published online the Clinical Management Guidelines for Acute Pancreatitis, which makes several recommendations to guide the clinical management of patients with acute pancreatitis (AP).
Diagnostic Recommendations
The diagnosis of AP is usually established by meeting two of the following three criteria: (i) the presence of symptoms of abdominal pain consistent with the disease, (ii) serum amylase and/or lipase levels that exceed the upper limit of the normal range by more than three times, and (iii) characteristic abdominal imaging findings.
2. CECT and/or MRI pancreatic examination is recommended for patients with unclear diagnosis or poor clinical outcome within 48 to 72 hours of initial hospitalization.
Recommendations for initial treatment
1. Patients should be given massive rehydration therapy (except in combination with cardiovascular and/or renal disease) with an hourly infusion of 250-500 mL of isotonic crystalloids. massive intravenous rehydration therapy is beneficial during the first 12 to 24 hours.
2. More rapid rehydration therapy (fluid pushing under pressure) is required for severely hypovolemic patients with manifestations of hypotension and tachycardia.
3.The first choice for isotonic crystalloid rehydration therapy is lactated Ringer’s solution.
4. The aim of massive rehydration is to reduce the patient’s serum urea nitrogen level. Therefore, patients should be reassessed frequently for fluid requirements during the first 6 hours of hospitalization and the following 24 to 48 hours.
Recommendations for ERCP examination in acute pancreatitis
1, Patients with AP combined with acute cholangitis should undergo ERCP within 24 hours of hospitalization.
2.If there is no laboratory or clinical evidence of gallstone pancreatitis in patients with biliary obstruction, ERCP is not required for the patient.
3, If the patient does not present with cholangitis and/or jaundice, MRCP or endoscopic ultrasound (EUS) should be chosen over diagnostic ERCP if there is a high suspicion of the presence of common bile duct stones.
4. In high-risk patients, to reduce their risk of severe pancreatitis after ERCP, endopancreatic ductal stents should be placed and/or intrarectal non-steroidal anti-inflammatory drug (NSAID) suppository therapy should be given postoperatively (conditional recommendation, moderate quality of evidence grade).
Recommendations for antibiotic treatment of acute pancreatitis
1, For patients with extra-pancreatic infections, such as cholangitis, duct-related infections, bacteremia, urinary tract infections and pneumonia, antibiotic therapy should be given.
2.For patients with severe AP, antibiotic prophylaxis is not recommended for routine use.
3.For patients with aseptic necrotizing pancreatitis, antibiotic therapy is not recommended to prevent the occurrence of infectious necrosis.
4. The presence of infectious necrotic foci should be considered in patients with pancreatic or extra-pancreatic necrotic foci and whose disease worsens or does not improve after 7 to 10 days of hospitalization. They should be treated with (i) early CT-guided needle aspiration biopsy (FNA) bacterial Gram stain and culture to guide the appropriate use of antibiotics, or (ii) no CT FNA examination and empirical antibiotic treatment.
5. For patients with infected necrotic foci, antibiotics known to penetrate pancreatic necrotic tissue, such as carbapenems, quinolones, and metronidazole, should be used during the delayed intervention period (or sometimes without surgical intervention at all) to reduce patient disability and mortality.
6. For patients treated prophylactically or therapeutically with antibiotics, routine treatment with antifungal drugs is not recommended.
Recommendations for surgical treatment of acute pancreatitis
1. If gallbladder stones are known to exist in the gallbladder of patients with mild AP, cholecystectomy should be performed before discharge to prevent recurrent attacks of AP.
In patients with acute necrotizing biliary pancreatitis, cholecystectomy should be postponed until the patient’s acute inflammatory response subsides and the peripancreatic fluid is absorbed or stabilized in order to prevent the occurrence of infection.
3. Patients with asymptomatic pancreatic and/or extra-pancreatic necrosis and/or pseudocyst formation, regardless of the size, location, and/or extent of the lesion, do not require interventional treatment.
4. Surgical, radiological, and endoscopic drainage treatment should be postponed during the stabilization period of patients with infected necrosis, and it is recommended to postpone it for at least 4 weeks to allow time for liquefaction of the necrotic foci and formation of the surrounding fibrous cyst wall (encapsulated necrotic foci).
In patients with infected necrotic foci and symptomatic manifestations, minimally invasive necrotic tissue debridement is preferred over open surgical necrotic tissue debridement.
Recommendations for nutritional support in acute pancreatitis
1. In patients with mild AP, once the nausea and vomiting disappears and the abdominal pain is relieved, the oral diet can be started immediately.
2. In the early diet of patients with mild AP, a low-fat solid diet and a dregs-free liquid diet are equally safe.
3. For patients with severe AP, enteral diet is recommended to prevent infectious complications. Unless enteral nutrition access cannot be established or the patient cannot tolerate enteral nutrition or enteral nutrition cannot meet the patient’s caloric needs, parenteral nutrition support therapy should be avoided as much as possible.
4. Transnasal gastrointestinal nutrition support therapy and transnasal jejunostomy nutrition support therapy are comparable in terms of efficacy and safety.