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Acute pancreatitis diagnosis and management: ACG guidelines

The American College of Gastroenterology practice guidelines for the diagnosis and management of acute pancreatitis appeared in the September 2013 issue of The American Journal of Gastroenterology.

The guidelines were developed after a MEDLINE search for data published between 1966 and 2012. The 34 recommendations in the guidelines address the diagnosis; etiology; initial assessment, risk stratification and management; the role of surgery, and the use of ERCP, antibiotics and surgery in patients with acute pancreatitis (AP).

“AP is one of the most common diseases of the gastrointestinal tract, leading to tremendous emotional, physical and financial human burden,” the researchers wrote. “During the past decade, there have been new understandings and developments in the diagnosis, etiology and early and late management of the disease.”

For diagnosing AP, the guidelines call for the presence of two of three criteria: abdominal pain consistent with AP, serum levels of amylase and/or lipase more than three times the upper limit of normal and/or results from abdominal imaging indicative of AP. Patients who do not experience clinical improvement within 48 to 72 hours of hospital admission or who have an unclear diagnosis should undergo contrast-enhanced CT.

The authors recommend that all patients diagnosed with AP undergo transabdominal ultrasound, and that hemodynamic status and organ failure be determined on presentation. Patients should receive early and aggressive hydration, in the absence of cardiovascular or renal comorbidities, with fluid requirements reassessed frequently. With concurrent acute cholangitis, ERCP should be performed within 24 hours of admission, but most patients with gallstone pancreatitis without signs of biliary obstruction do not require the procedure.

Administration of antibiotics to treat extrapancreatic infection was recommended, but not for severe AP, or to prevent infected necrosis in patients with sterile necrosis. Patients with severe AP should receive enteral nutrition to avoid infectious complications.

Patients with gallstones and mild AP should undergo cholecystectomy before discharge to avoid recurrence, while the procedure should be deferred in cases with necrotizing biliary AP until inflammation and fluid collections subside. The authors also recommend that stable patients with infected necrosis not undergo drainage for more than 4 weeks, while symptomatic patients with infected necrosis should receive minimally invasive rather than open necrosectomy.

Additional Resources:

Curbside Consultation: When Should I Consider Performing a Computed Tomography of the Abdomen in Patients With Acute Pancreatitis? - Nison Badalov, MD and Scott Tenner, MD, MPH

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