MD Nexus

Acute Pancreatitis

Epidemiology

Etiology

General Comments

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients >40 y/o without an Established Etiology of Acute Pancreatitis a Pnacreatic Tumor SHould Be Considered as a Possible Etiology of Acute Pancreatitis
  • Following a Second Episode of Acute Pancreatitis with No Identifiable Etiology (and the Ability to Tolerate Surgery), a Cholecystectomy Should Be Performed to Decrease the Risk Recurrent Acute Pancreatitis Episodes

Congenital

Choledochocele Type V

  • Epidemiology
    • XXXX

Pancreas Divisum

  • Epidemiology
    • XXXXX

Genetic

Cystic Fibrosis (CF) (see Cystic Fibrosis)

  • Epidemiology
    • XXXX
  • Clinical
    • XXXXX

Serine Protease I Gene (PRSSS1) Mutation

  • Epidemiology
    • XXXX
  • Physiology
    • Encodes for Cationic Trypsinogen

Serine Protease Inhibitor Kazal Type 1 (SPINK1) Mutation

  • Epidemiology
    • XXXX

Chymotrypsin C (CTRC) Gene Mutation

  • Epidemiology
    • XXXX

Infection

Ascariasis (see Ascariasis)

  • Epidemiology
    • XXXX
  • Physiology
    • Due to Mechanical Obstruction

Aspergillus (see Aspergillus)

  • Epidemiology
    • XXXX

Coxsackie Virus (see Coxsackie Virus)

  • Epidemiology
    • XXXX

Cryptosporidiosis (see Cryptosporidiosis)

  • Epidemiology
    • XXXX

Cytomegalovirus (CMV) (see Cytomegalovirus)

  • Epidemiology
    • XXXX

Hepatitis B Virus (HBV) (see Hepatitis B Virus)

  • Epidemiology
    • XXXX

Herpes Simplex Virus (HSV) (see Herpes Simplex Virus)

  • Epidemiology
    • XXXX

Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus)

  • Epidemiology
    • XXXX

Legionellosis (see Legionellosis)

  • Epidemiology
    • XXXX

Leptospirosis (see Leptospirosis)

  • Epidemiology
    • Cases Reported in Children

Mycoplasma (see Mycoplasma)

  • Epidemiology
    • XXXX

Mumps Virus (see Mumps Virus)

  • Epidemiology
    • XXXX

Salmonella (see Salmonella)

  • Epidemiology
    • XXXX

Toxoplasmosis (see Toxoplasmosis)

  • Epidemiology
    • XXXX

Varicella-Zoster Virus (VZV) (see Varicella-Zoster Virus)

  • Epidemiology
    • XXXX

Mechanical Ampullary Obstruction

Ampullary Stenosis

  • Epidemiology
    • XXXXX
  • Clinical
    • XXXXX

Biliary Sludge

  • Physiology
    • Due to Biliary Stasis
    • Biliary Sludge Contains Cholesterol Monohydrate Crystals, Calcium Bilirubinate Granules, and Possibly Stones
  • Clinical
    • XXXX

Duodenal Obstruction/Stricture

  • Epidemiology
    • XXXXX
  • Clinical
    • XXXXX

Gallstones (see Cholelithiasis)

  • Epidemiology
    • Gallstones are the Most Common Etiology of Acute Pancreatitis in Most Areas of the World
      • Gallstones Account for Approximately 35-40% of All Acute Pancreatitis Cases
      • However, Only 3-7% of Patients with Gallstones Develop Acute Pancreatitis
    • Risk Factors
      • Male Sex
        • Males Have a Higher Risk of Developing Acute Pancreatitis in the Presence of Gallstones
        • Females Have a Higher Incidence of Gallstone Pancreatitis Due to a Higher Prevalence of Gallstones
      • Gallstone Size <5 mm
        • Gallstones <5 mm are More Likely to Pass Through the Cystic Duct and Cause Ampullary Obstruction
  • Physiologic Mechanisms
    • Ampullary Obstruction Due to the Gallstone Itself (or Due to Edema Associated with Passage of the Gallstone)
    • Reflux of Bile into the Pancreatic Duct Due to Transient Obstruction of the Ampulla During Gallstone Passage

Intraductal Papillary Mucinous Neoplasm (IPMN)

  • Epidemiology
    • May Be Seen in Elderly Non-Alcoholic Males
  • Clinical
    • XXXXXX

Pancreatic Cancer (see Pancreatic Cancer)

  • Epidemiology
    • XXXXX
  • Clinical
    • XXXXX

Periampullary Cancer

  • Epidemiology
    • XXXXX
  • Clinical
    • XXXX

Periampullary Diverticulum

  • Epidemiology
    • XXXXX
  • Clinical
    • XXXXX

Metabolic

Hypercalcemia (see Hypercalcemia)

  • Epidemiology
    • Hypercalcemia is an Uncommon Etiology of Acute Pancreatitis
    • Hypercalcemia of Any Etiology Can Cause Acute Pancreatitis
  • Physiologic Mechanisms
    • Deposition of Calcium in Pancreatic Duct
    • Calcium Activation of Trypsinogen within the Pancreatic Parenchyma

Hypertriglyceridemia (see Hypertriglyceridemia)

  • Epidemiology
    • Hypertriglyceridemia Accounts for 1-4% of Acute Pancreatitis Cases (J Clin Gastroenterol, 2014) [MEDLINE]
    • Hyperlipidemia Types I/IV/V (see Hyperlipidemia)
  • Physiology
    • Acute Pancreatitis May Occur in the Setting of Serum Triglycerides >1000 mg/dL

Trauma/Surgery/Procedures

Blunt Abdominal Trauma

  • Epidemiology
    • XXXX

Penetrating Abdominal Trauma

  • Epidemiology
    • XXXX
  • Clinical
    • XXXX

Iatrogenic Injury During Surgery/Endoscopic Retrograde Cholangiopancreatography (ERCP) (see Endoscopic Retrograde Cholangiopancreatography)

  • Epidemiology
    • Acute Pancreatitis is the Most Common Complication of Endoscopic Retrograde Cholangiopancreatography (ERCP)
    • Asymptomatic Hyperamylasemia Occurs in 35-70% of Patients Following Endoscopic Retrograde Cholangiopancreatography (ERCP)
    • However, Acute Pancreatitis Occurs in 3% of Patients Following Diagnostic Endoscopic Retrograde Cholangiopancreatography (ERCP), 5% of Patients Following Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP), and 25% of Patients Following Sphincter of Oddi Manometry Studies

Vascular

Cholesterol Emboli Syndrome (see Cholesterol Emboli Syndrome)

  • Epidemiology
    • XXXXXXXXXXX
  • Clinical
    • XXXXXXX

Pancreatic Ischemia

Vasculitis (see Vasculitis)

Drugs

General Comments

  • Medications Account for Only 0-3-1.4% of Acute Pancreatitis Cases

Class Ia Drugs (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Class Ib Drugs (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Class II Drugs (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Class III Drugs (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Class IV Drugs (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Toxin

Ethanol (see Ethanol)

  • Epidemiology
    • Ethanol Consumption Accounts for 30% of Acute Pancreatitis Cases in the United States
    • XXXXX
  • Physiologic Mechanisms
    • Increased Synthesis Digestive/Lysosomal Enzymes by Pancreatic Acinar Cells
    • Oversensitization of Pancreatic Acini to Cholecystokinin

Marijuana (see Tetrahydrocannabinol)

  • Epidemiology
    • Case Has Been Reported with Smoked Marijuana, Considered Class Ia (Clin Gastroenterol Hepatol, 2007) [MEDLINE]

Methanol (see Methanol)

  • Epidemiology
    • XXXX

Organophosphate/Carbamate Intoxication (see Organophosphates/Carbamates)

  • Epidemiology
    • Acute Pancreatitis Has Been Reported with Both Organophosphates and Carbamates (Hum Exp Toxicol, 2002) [MEDLINE]

Scorpion Sting (see Scorpion Sting)

  • Epidemiology
    • XXXX

Strychnine (see Strychnine)

  • Epidemiology
    • XXXX

Tobacco Abuse (see Tobacco)

  • Epidemiology
    • Tobacco is an Independent Risk Factor for the Development of Both Acute and Chronic Pancreatitis

Other

Alpha-1 Antitrypsin (A1AT) Deficiency (see Alpha-1 Antitrypsin Deficiency)

  • Epidemiology
    • XXXXXXXXXX
  • Clinical
    • XXXX

Pregnancy (see Pregnancy)

  • Epidemiology
    • XXXXXXXXX

Renal Transplant (see Renal Transplant)

  • Epidemiology
    • XXXXXXXX

Physiology

XXXXXXXXXXXXXXXXX

Diagnosis

Serum Amylase (see Hyperamylasemia)

Time Course

  • Serum Amylase Increases within 6-12 hrs of the Onset of Acute Pancreatitis
  • In Uncomplicated Acute Pancreatitis, Serum Amylase Returns to Normal within 3-5 Days

Half-Life

  • Half-Life of Serum Amylase: 10 hrs
    • Due to Short Half-Life, Serum Amylase May Not Be Elevated in Patients Who Present >24 hrs After the Onset of Acute Pancreatitis

Sensitivity/Specificity for Acute Pancreatitis (Using Serum Amylase >3x Upper Limit of Normal)

  • Sensitivity: 67-83%
    • In Alcoholic Pancreatitis, Serum Amylase Elevation to >3x Upper Limit of Normal is Not Seen in 20% of Cases (Due to Inability of Pancreas to Synthesize Amylase)
  • Specificity: 85-98%

Serum Lipase (see Serum Lipase)

Time Course of Serum Lipase Elevation

  • Serum Lipase Increases within 4-8 hrs of Onset of Acute Pancreatitis
  • Serum Lipase Peaks at 24 hrs: makes lipase particularly useful in patients who present >24 hrs after onset of acute pancreatitis
  • Serum Lipase Returns to Normal within 8-14 Days

Half-Life

  • Half-Life of Serum Lipase: 7-14 hrs

Sensitivity/Specificity for Acute Pancreatitis

  • Sensitivity: 82-100%
    • Lipase is More Sensitive than Amylase in Alcoholic Pancreatitis
  • Specificity: 82-100%

Serum Trypsinogen Activation Peptide (TAP)

  • Trypsinogen activation peptide is a 5 amino acid peptide that is cleaved from trypsinogen (to produce active trypsin)
  • Elevated in acute pancreatitis
    • May be sensitive for early acute pancreatitis
    • May be sensitive as a predictor of severity of acute pancreatitis

Urinary/Serum Trypsinogen-2

  • Urinary/Serum Trypsinogen May Be Elevated in Early Acute Pancreatitis
    • Role of Their Measurement is Currently Unclear

Serum Triglyceride (see Serum Triglyceride)

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • In the Absence of Gallstones and/or Significant Alcohol Use, Serum Triglyceride Should Be Obtained and Considered the Etiology if >1000 mg/dL (Conditional Recommendation, Moderate Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In the Absence of Gallstones and/or Significant Alcohol Use, Serum Triglyceride Should Be Obtained and Considered the Etiology of Acute Pancreatitis if the Serum Triglycerides are >1000 mg/dL

Abdominal/Pelvic Ultrasound (see Abdominal/Pelvic Ultrasound)

General Comments

  • Abdominal/Pelvic Ultrasound is Less Accurate than Abdominal/Pelvic Computed Tomography (CT) for the Diagnosis of Pancreatic Necrosis

Recommendations (American College of Gastroenterology Practice Guidelines 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Abdominal Ultrasound Should Be Performed in All Patients with Acute Pancreatitis (Strong Recommendation, Low Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Abdominal Ultrasound is Recommended in Acute Pancreatitis to Evaluate for Biliary Pancreatitis (Conditional Recommendation, Very Low Quality of Evidence)
    • If the Initial Unltrasound is Inconclusive, a Repeat Ultrasound is Recommended
  • In Patients with Idiopathic Acute Pancreatitis, Additional Diagnostic Evaluation with Repeat Abdominal Ultrasound, Magentic Resonance Cholangiopancreatography (MRCP), and/or Endoscopic Ultrasound is Recommended (Conditional Recommendation, Very Low Quality of Evidence)

Abdominal/Pelvic Computed Tomography (CT) (see Abdominal/Pelvic Computed Tomography)

General Comments

  • Since Pancreatic Necrosis Takes Time to Develop, Computed Tomography (CT) May Be Normal in the First 48 hrs
  • The Association Between Contrast iInjection and Worsening of Acute Pancreatitis is Not Strong
    • Therefore, Comuted Tomography (CT) is Not Contraindicated
  • Sensitivity of Computed Tomography (CT) for the Diagnosis of Acute Pancreatitis: >90%
  • Specificity of Computed Tomography (CT) for the Diagnosis of Acute Pancreatitis: >90%

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Contrast-Enhanced Computed Tomography and/or Magnetic Resonance Imaging 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 hrs After Hospital Admission or to Evaluate for Complications (Strong Recommendation, Low Quality of Evidence)
  • In a Patient >40 y/o, a Pancreatic Tumor Should Be Considered as a Possible Cause of Acute Pancreatitis (Conditional Recommendation, Low Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Early (or at Admission) Computed Tomograpy (CT) is Not Recommended for the Purposes of Determining the Severity of Acute Pancreatitis
    • Computed Tomography (CT) Should Be Reserved for Patients in Whom the Diagnosis is Unclear or Who Fail to Clinically Improve within the First 48-72 hrs After Hospital Admission and Intravenous Fluid Resuscitation

Endoscopic Retrograde Cholangiopancreatography (ERCP) with (see Endoscopic Retrograde Cholangiopancreatography)

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • 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 Acute Pancreatitis and Concurrent Acute Cholangitis Should Undergo Endoscopic Retrograde Cholangiopancreatography (ERCP) within 24 hrs of Admission (Strong Recommendation, Moderate Quality of Evidence)
    • ERCP is Not Required in Most Patients with Gallstone Pancreatitis Who Lack Laboratory or Clinical Evidence of Ongoing Biliary Obstruction (Strong Recommendation, Low Quality of Evidence)
  • Prevention of Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis
    • 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 Recommendation, Moderate Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Acute Biliary Pancreatitis without Cholangitis, Medical Therapy is Recommended Over Early (within the First 72 hrs) Endoscopic Retrograde Cholangiopancreatography (ERCP) (Conditional Recommendation, Low Quality of Evidence)
    • In the Absence of Cholangitis and/or Jaundice, if a Common Bile Duct Stone is Suspected, Magnetic Resonance Cholangiopancreatography (MRCP) or Endoscopic Ultrasound (EUS) Should Be utilized to Screen for the Presence of a Common Bile Duct Stone Prior to Endoscopic Retrograde Cholangiopancreatography (ERCP)
  • In Acute Biliary Pancreatitis with Cholangitis, Early (within 24 hrs) Endoscopic Retrograde Cholangiopancreatography (ERCP) Decreases Morbidity and Mortality

Magnetic Resonance Cholangiopancreatography (MRCP) (see Magnetic Resonance Cholangiopancreatography)

Recommendations (American College of Gastroenterology Practice Guidelines 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • 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)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients with Idiopathic Acute Pancreatitis, Additional Diagnostic Evaluation with Repeat Abdominal Ultrasound, Magentic Resonance Cholangiopancreatography (MRCP), and/or Endoscopic Ultrasound is Recommended (Conditional Recommendation, Very Low Quality of Evidence)

Genetic Testing

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Genetic Testing May Be Considered in Young Patients (< 30 y/o) if No Etiology is Evident and a Family History of Pancreatic Disease is Present (Conditional Recommendation, Low Quality of Evidence)

Fine Needle Aspiration of Pancreatic Necrosis

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients with Suspected Infected Pancreatic Necrosis, Fine Needle Aspiration is Not Recommended (Conditional Recommendation, Very Low Quality of Evidence)

Clinical Scoring of Acute Pancreatitis

General Comments

  • Approximately 15-25% of Patients with Acute Pancreatitis Develop Moderately Severe or Severe Acute Pancreatitis
  • None of the Available Scoring Systems Demosntrates High Accuracy in Precicting the Severity of Acute Pancreatitis in Any Given Patient (Gastroenterology, 2012) [MEDLINE] (Pancreas, 2013) [MEDLINE]
    • For This Reason, Many of the Scoring Systems are Not Routinely Used in Clinical Practice

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Scoring Systems and Imaging Alone are Not Accurate in Determining Which Patients with Acute Pancreatitis Will Develop Moderately-Severe or Severe Acute Pancreatitis
  • In Patients with Mild Acute Pancreatitis, Clinicians Should Be Vigilant for the Development of Organ Failure or Severe Acute Pancreatitis During the First 48 hrs of Admission
  • Risk Factors for the Development of Severe Acute Pancreatitis
    • Altered Mental Status (see Altered Mental Status)
    • Clinical Indicators of Hemoconcentration
      • Blood Urea Nitrogen (BUN) >20 mg/dL (or Rising Blood Urea Nitrogen)
      • Creatinine ≥2 mg/dL
      • Hematocrit >44% (or Rising Hematocrit)
    • Comorbidities
    • Obesity (with BMI >30 kg/m2) (see Obesity)
    • Systemic Inflammatory Response Syndrome (SIRS): ≥2 of the Following
      • Heart Rate >90 Beats/min
      • Respiratory Rate >20 Breaths/min
      • Temperature <36 °C or >38 °C
      • White Blood Cell Count <4,000 Cells/mm3 or >12,000 Cells/mm3
    • Radiographic Findings
      • Pleural Effusions
      • Pulmonary Infiltrates
      • Multiple or Extensive Extrapancreatic Collections

Ranson’s Criteria

General Comments

  • Ranson’s Criteria were One of the Earliest Scoring Systems Used for Acute Pancreatitis (Surg Gynecol Obstet, 1974) [MEDLINE]
  • Calculation of Ranson’s Criteria Takes 48 hrs to Complete

Original Ranson’s Criteria (Surg Gynecol Obstet, 1974) [MEDLINE]

  • 0 Hour Criteria
    • Age >55
    • White Blood Cell (WBC) Count >16k
    • Blood Glucose >200 mg/dL
    • Lactate Dehydrogenase (LDH) >350 U/L
    • Aspartate Aminotransferase (AST) >250 U/L
  • 48 Hour Criteria
    • Base Deficit >4 MEq/L
    • Increase in Blood Urea Nitrogen (BUN) by ≥5 mg/dL (1.8 mmol/L) Despite Intravenous Fluids
    • Fluid Sequestration >6000 mL
    • Hematocrit Decrease by ≥10%
    • pO2 <60 mmHg
    • Serum Calcium <8 mg/dL (2 mmol/L)

Original Ranson’s Criteria Scoring

  • Score <3 (Mild Pancreatitis): mortality rate is is 0-3%
  • Score ≥3: mortality rate is 11-15%
  • Score ≥6: mortality rate is 40%

Revised Criteria of Ranson’s Criteria for Patients with Biliary Acute Pancreatitis (Ann Surg, 1979) [MEDLINE]

  • This was System (Which Only Used 10 Clinical Features) was Developed for Biliary Acute Pancreatitis

Clinical Efficacy

  • Meta-Analysis of Original Ranson’s Criteria in Acute Pancreatitis (Crit Care Med, 1999) [MEDLINE]: n= 110 studies
    • Ranson’s Criteria Demonstrated Poor Predictive Power
    • The Information Content Did Not Differ from That of Clinical Judgment

Acute Physiology and Chronic Health Examination (APACHE) II Score

General Comments

  • History
    • APACHE II Score was Originally Developed for Critically Ill Patients in the Intensive Care Unit (ICU)
    • APACHE II Score is Probably the Most Widely Studied Severity Scoring System in Acute Pancreatitis
  • Performance
    • Good Negative Predictive Value
    • Modest Positive Predictive Value for Predicting Severe Acute Pancreatitis
    • However, it Has a Poor Predictive Value at 24 hrs (Am J Gastroenterol, 2006) [MEDLINE]
  • Convenience
    • While APACHE II Scoring is Complex and Cumbersome to Use, it Can Be Performed Daily
      • Decreasing Values During First 48 hrs Indicate Mild Acute Pancreatitis, While Increasing Values During the First 48 hrs Indicate Severe Acute Pancreatitis
  • Disadvantages
    • APACHE II Scoring Does Not Differentiate Between Interstitial and Necrotizing Pancreatitis
    • APACHE II Scoring Does Not Differentiate Between Sterile and Infected Necrosis

Clinical Efficacy

  • Score <8 Precicts a Mortality Rate <4%, While Score >8 Predicts a Mortality Rate 11-18% (Am J Gastroenterol, 2006) [MEDLINE]

Systemic Inflammatory Response Syndrome (SIRS) Score

General Comments

  • xxx

Clinical Efficacy

  • xxx

Bedside Index of Severity in Acute Pancreatitis (BISAP) Score

General Comments

  • xxx

Clinical Efficacy

  • xxx

Harmless Acute Pancreatitis Score

General Comments

  • xxx

Clinical Efficacy

  • xxx

Organ Failure-Based Scores

General Comments

  • xxx

Clinical Efficacy

  • xxx

Computed Tomography(CT) Severity Index

General Comments

  • xxx

Clinical Efficacy

  • xxx

Clinical Manifestations

Diagnostic Criteria for Acute Pancreatitis (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Diagnosis of Acute Pancreatitis is Most Often Established by the Presence of 2 of the 3 Following Criteria (Strong Recommendation, Moderate Quality of Evidence)
    • Abdominal Pain Consistent with the Disease
    • Serum Amylase and/or Lipase >3x the Upper Limit of Normal
    • Characteristic Findings from Abdominal Imaging

Definitions (Arch Surg, 1993) [MEDLINE] (Gut, 2013) [MEDLINE]

  • Interstitial Edematous Acute Pancreatitis
    • Acute Inflammation of the Pancreatic Parenchyma and Peripancreatic Tissues, But without Recognizable Tissue Necrosis
    • Contrast-Enhanced Computed Tomography Criteria
      • Pancreatic Parenchyma Enhancement by Intravenous Contrast Agent
      • No Findings of Peripancreatic Necrosis
  • Necrotizing Acute Pancreatitis
    • Inflammation Associated with Pancreatic Parenchymal Pecrosis and/or Peripancreatic Necrosis
    • Contrast-Enhanced Computed Tomography Criteria (Either or Both of the Following)
      • Absence of Pancreatic Parenchymal Enhancement by Intravenous Contrast Agent
      • Presence of Findings of Peripancreatic Necrosis
        • Refer to Below–Acute Peripancreatic Fluid Collection and Walled Off Necrosis
  • Acute Peripancreatic Fluid Collection (APFC)
    • Peripancreatic fluid associated with interstitial edematous pancreatitis with no associated peripancreatic necrosis
      • This term applies only to areas of peripancreatic fluid seen within the first four weeks after onset of interstitial edematous pancreatitis and without the features of a pseudocyst
    • Contrast-Enhanced Computed Tomography Criteria
      • Occurs in the setting of interstitial edematous pancreatitis
      • Homogeneous collection with fluid density
      • Confined by normal peripancreatic fascial planes
      • No definable wall encapsulating the collection
      • Adjacent to pancreas (no intrapancreatic extension)
  • Pancreatic Pseudocyst
    • Encapsulated Collection of fluid with a well-defined inflammatory wall usually outside the pancreas with minimal or no necrosis
      • This entity usually occurs more than four weeks after onset of interstitial edematous pancreatitis to mature
    • Contrast-Enhanced Computed Tomography Criteria
      • Well circumscribed, usually round or oval
      • Homogeneous fluid density
      • No non-liquid component
      • Well-defined wall (ie, completely encapsulated)
      • Maturation usually requires >4 weeks after onset of acute pancreatitis
        • Occurs after interstitial edematous pancreatitis
  • Acute Necrotic Collection (ANC)
    • Collection containing variable amounts of both fluid and necrosis associated with necrotizing pancreatitis
      • the necrosis can involve the pancreatic parenchyma and/or the peripancreatic tissues
    • Contrast-Enhanced Computed Tomography Criteria
      • Occurs only in the setting of acute necrotizing pancreatitis
      • Heterogeneous and non-liquid density of varying degrees in different locations (some appear homogeneous early in their course)
      • No definable wall encapsulating the collection
      • Location–intrapancreatic and/or extrapancreatic
  • Walled-Off Necrosis (WON)
    • A mature, encapsulated collection of pancreatic and/or peripancreatic necrosis that has developed a well-defined inflammatory wall
      • WON usually occurs >4 weeks after onset of necrotizing pancreatitis
    • Contrast-Enhanced Computed Tomography Criteria
      • Heterogeneous with liquid and non-liquid density with varying degrees of loculations (some may appear homogeneous)
      • Well-Defined Wall (i.e. Completely Encapsulated)
      • Location–intrapancreatic and/or extrapancreatic
      • Maturation usually requires four weeks after onset of acute necrotizing pancreatitis

Disease Severity

  • Mild Acute Pancreatitis
    • Absence of Organ Failure and Local/Systemic Complications
  • Moderately Severe Acute Pancreatitis
    • Absence of Organ Failure or Transient Organ Failure (≤48 hrs) and/or Local Complications
  • Severe acute pancreatitis
    • Persistent Organ Failure (>48 hrs) Which May Involve >=1 Organs

Modified Marshall Scoring System for Organ Dysfunction (Gut, 2013) [MEDLINE]

  • Respiratory
    • pO2/FiO2 Ratio >400: 0 pts
    • pO2/FiO2 Ratio 301-400: 1 pts
    • pO2/FiO2 Ratio 201-300: 2 pts
    • pO2/FiO2 Ratio 101-200: 3 pts
    • pO2/FiO2 Ratio ≤101: 4 pts
    • For Non-Ventilated Patients
      • Room Air = 21%
      • 2 L/min= 25%
      • 4 L/min = 30%
      • 6-8 L/min = 40%
      • 9-10 L/min = 50%
  • Renal
    • Serum Creatinine <1.4 mg/dL: 0 pts
    • Serum Creatinine 1.4-1/8 mg/dL: 1 pts
    • Serum Creatinine 1.9-3.6 mg/dL: 2 pts
    • Serum Creatinine 3.6-4.9mg/dL: 3 pts
    • Serum Creatinine >4.9 mg/dL: 4 pts
  • Cardiovascular
    • Systolic Blood Pressure >90 mm Hg: 0 pts
    • Systolic Blood Pressure <90 mm Hg (Fluid Resposince): 1 pts
    • Systolic Blood Pressure <90 mm Hg (Not Fluid Responsive: 2 pts
    • Systolic Blood Pressure <90 mm Hg (pH <7.3): 3 pts
    • Systolic Blood Pressure <90 mm Hg (pH <7.2): 4 pts
  • Score ≥2 in Any Category Defines the Presence of Organ Failure
  • Score for Patients with Pre-existing Chronic Renal Failure Depends on the Extent of Further Deterioration of Baseline Renal Function
    • No Formal Correction Exists for a Baseline Serum Creatinine ≥1.4 mg/dL (≥134 micromol/L)

Cardiovascular Manifestations

Hypotension/Hypovolemia (see Hypotension and Hypovolemic Shock)

  • Epidemiology
    • XXXXX
  • Physiology
    • XXXX

Gastrointestinal Manifestations

Abdominal Pain (see Abdominal Pain)

  • Epidemiology
    • Abdominal Pain is Common

Nausea and Vomiting (see Nausea and Vomiting)

  • Epidemiology
    • Nausea/Vomiting is Common

Hematologic Manifestations

Acquired Von Willebrand Disease (see Von Willebrand Disease)

  • Physiology
    • Hyperfibrinolytic State, Resulting in VWF Degradation by Proteolytic Enzymes (Such as Plasmin)

Hemoconcentration

  • Physiology
    • Hemoconcentration May Occur Due to Third-Space Fluid Loss
  • Clinical
    • Blood Urea Nitrogen (BUN) >20 (or Rising Blood Urea Nitrogen)
    • Creatinine ≥2 mg/dL
    • Hematocrit >44% (or Rising Hematocrit)
  • Prognosis
    • Presence of Hemoconcentration Has Variable Performance as a Predictor of Severe Acute Pancreatitis (Likely Due to Differences in the Cutoff Value Used and the Time that Values were Obtained in Studies) (Am J Gastroenterol, 1998) [MEDLINE] (Pancreas, 2000) [MEDLINE] (Am J Gastroenterol, 2001) [MEDLINE] (World J Gastroenterol, 2005) [MEDLINE] (Am J Gastroenterol, 2009) [MEDLINE]
    • In General, Normal or Low Hematocrit at Admission and During the First 24 hrs is Associated with a Milder Clinical Course

Pulmonary Manifestations

Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)

  • Epidemiology
    • Acute Respiratory Distress Syndrome (ARDS) May Occur in Some Cases
  • Predictors of Acute Respiratory Distress Syndrome (ARDS) in the Setting of Severe Acute Pancreatitis (World J Gastroenterol, 2022) [MEDLINE]
    • Blood Urea Nitrogen (Odds Ratio 1.12; 95% CI: 1.05-1.19, P < 0.001)
    • Heart Rate (Odds Ratio = 1.05; 95% CI: 1.03-1.07, P < 0.001)
    • Respiratory Rate (Odds Ratio 1.10; 95% CI: 1.02-1.19, P = 0.014)
    • Serum Calcium (Odds Ratio 0.17; 95% CI: 0.06-0.48, P = 0.001)
  • Physiology
    • May Be Mediated by Cytokine Release (Indian J Gastroenterol, 2020) [MEDLINE]
  • Prognosis
    • Associated with High Mortaliy Rate in the Setting of Acute Pancreatitis

Pleural Effusion (see Pleural Effusion-Exudate)

  • Epidemiology
    • Pleural Effusion Occurs in 3-17% of Acute Pancreatitis Cases

Renal Manifestations

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

  • Physiology
    • Acute Kidney Injury (AKI) May Occur Due to Third-Space Fluid Loss (and Other Factors)
  • Prognosis (Based on Increased Blood Urea Nitrogen, BUN) (see Increased Blood Urea Nitrogen)
    • In a Large Hospital-Based Cohort, Increased Blood Urea Nitrogen (BUN) was the Most Reliable Laboratory Indicator to Predict the Mortality Rate in Severe Acute Pancreatitis (Gastroenterology, 2009) [MEDLINE]
      • For Every Increase in BUN of 5 mg/dL During the First 24 hrs, the Adjusted Odds Ratio for Mortality was 2.2
    • Another Study (n = 1,043) Demonstrated that BUN ≥20 mg/dL at Admission was Associated with an Increased Mortality Rate, as Compared to a BUN <20 mg/dL (Odds Ratio 4.6) (Arch Intern Med, 2011) [MEDLINE]
      • Additionally, Any Increase in BUN at 24 hrs was Associated with an Increased Mortality Rate (Odds Ratio 4.3)
  • Prognosis (Based on Increased Serum Creatinine) (see Increased Serum Creatinine)
    • In a Study (n = 129), Peak Creatinine >1.8 mg/dL During the First 48 hrs Had a Positive Predictive Value of 93% for the Development of Pancreatic Necrosis (Am J Gastroenterol, 2009) [MEDLINE]
    • However, in a German Study, This Association was Not Observed, Although it Did Demonstrate that a Normal Serum Creatinine Had a High Negative Predictive Value for the Development of Pancreatic Necrosis (Am J Gastroenterol, 2010) [MEDLINE]
      • Authors Suggested that a Normal Serum Creatinine in the Absence of Complications Obviated the Need for an Abdominal Computed Tomographic (CT) Scan
      • Importantly, This Study Had a Lower Prevalence of Pnacreatic Necrosis, Which Could Have Resulted in a Lower Positive Predictive Value

Hypocalcemia (see Hypocalcemia)

  • Clinical
    • Prospective Study of Hypocalcemia in Patients with Acute Pancreatitis (Ann Gastroenterol, 2016) [MEDLINE]
      • Approximately 35.2% of Patients Had Hypocalcemia
      • Patients with Hypocalcemia Had Significantly Higher Frequency of Persistent Organ Failure, Mortality, and Need for Intervention (P<0.05)
      • Approximately 32.4% of the Patients with Hypocalcemia Had Tetany
      • Patients with Tetany Had Significantly Lower Serum Corrected Calcium and Ionized Calcium Levels, as Compared to Patients with Asymptomatic Hypocalcemia (P<0.05)
      • Patients with Tetany Had Significantly Higher Mortality Rates, as Compared to Patients with Asymptomatic Hypocalcemia (100% vs. 8%; P=0.00001) as Well as Persistent Organ Failure (100% vs. 32%; P=0.000006)

Hypophosphatemia (see Hypophosphatemia)-

  • Epidemiology
    • Cases of Acute Pancreatitis (Unrelated to Alcohol Use) Resulting in Hypophosphatemia Have Been Reported (Dig Dis Sci, 2006) [MEDLINE]
  • Physiology
    • XXXXX
  • Clinical
    • XXXXX

Prevention

Prevention of Post-Endoscopic Retrograde Cholangiopancreatiography (ERCP) Pancreatitis

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Pancreatic Duct Stents and/or Postprocedure Rectal Nonsteroidal Anti-Inflammatory Drug (NSAID) Suppositories Should Be Utilized to Prevent Severe Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis in High-Risk Patients (Conditional Recommendation, Moderate Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Acute Pancreatitis, Rectal Indomethacin is Recommended to Prevent Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Acute Pancreatitis (Strong Recommendation, Moderate Quality of Evidence)
  • In Patients at High Risk for Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Acute Pancreatitis Who are Reciving Rectal Indomethacin, Placement of a Pancreatic Duct Stent is Recommended (Conditional Recmmendation, Low Quality of Evidence)

Treatment

General Management

Indications for Monitored or Intensive Care (Crit Care Med, 1999) [MEDLINE] (Gut, 2005) [MEDLINE] (Pancreatology, 2013) [MEDLINE]

  • Patients with Severe Acute Pancreatitis
    • In Patients with Severe Acute Pancreatitis, Intensive Care Unit (ICU) Monitoring and Pulmonary/Renal/Circulatory/Hepatobiliary Organ Support May Minimize Systemic Sequelae (Gut, 2005) [MEDLINE]
  • Patients with Acute Pancreatitis and ≥1 of the Following
    • Bradycardia with Heart Rate (HR) <40 Beats/min or Tachycardia with >150 beats/min (see Sinus Bradycardia and Sinus Tachycardia)
    • Hypotension as Defined by Systolic Arterial Blood Pressure (SBP) <80 mm Hg or Mean Arterial Pressure (MAP) <60 mm Hg or Diastolic Arterial Blood Pressure (DBP) >120 mm Hg (see Hypotension)
    • Tachypnea with Respiratory Rate (RR) >35 breaths/min (see Tachypnea)
    • Hyponatremia with Serum Sodium <110 mmol/L or Hypernatremia >170 mmol/L (see Hyponatremia and Hypernatremia)
    • Hypokalemia with Serum Potassium <2.0 mmol/L or Hyperkalemia with >7.0 mmol/L (see Hypokalemia and Hyperkalemia)
    • Hypoxemia with pO2 <50 mm Hg (see Hypoxemia and Respiratory Failure)
    • Acidemia with pH <7.1 or Alkalemia with >7.7
    • Hyperglycemia with Serum Glucose >800 mg/dL (see Hyperglycemia)
    • Hypercalcemia with Serum Calcium >15 mg/dL (see Hypercalcemia)
    • Anuria
    • Coma (see Obtundation/Coma)

Transfer to a Monitored or Intensive Care Unit May Be Considered in Patients with the Following Clinical Findings (Gastroenterology, 2013) [MEDLINE]

  • Age >60 y/o
  • Increased Hematocrit (>44%), Increased Blood Urea Nitrogen (BUN) (>20 mg/dL), or Increased Creatinine (>1.8 mg/dL)
  • Underlying Comorbities
    • Cardiac Disease
    • Pulmonary Disease
    • Obesity (see Obesity)
  • Persistent (>48 hrs) SIRS (≥2 of the Following)
    • Hyperthermia with Temperature >38.3°C or Hypothermia <36.0°C (see Fever and Hypothermia)
    • Tachycardia with Heart Rate >90 Beats/min (see Tachycardia)
    • Tachypnea with Respiratory Rate of >20 breaths/min or pCO2 <32 mm Hg (see Tachypnea)
    • Leukocytosis with White Blood Cell (WBC) Count >12,000 cells/mm3, Leukopenia with <4000 cells/mm3, or Bandemia with >10% Immature (Band) Forms (see Leukocytosis and Leukopenia)

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Triage Between Medical Facilities
    • Patients with Idiopathic Acute Pancreatitis Should Be Referred to a Center of Expertise (Conditional Recommendation, Low Quality of Evidence)
  • Triage within a Medical Facility
    • Hemodynamic Status Should Be Assessed Immediately Upon Presentation and Resuscitative Measures Begun, as Required (Strong Recommendation, Moderate Quality of Evidence)
    • Risk Assessment Should Be Performed to Stratify Patients into Higher and Lower Risk Categories to Assist Triage, Such as Intensive Care Unit Admission (Conditional Recommendation, Moderate Quality of Evidence)
    • Patients with Organ Failure Should Be Admitted to an Intensive Care Unit or Intermediate Care Setting Whenever Possible (Strong Recommendation, Low Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Hemodynamic Status and Risk Assessment Should Be Performed to Risk Stratify Patients into High-Risk and Low-Risk Groups to Assist Triage to an Unmonitored vs Monitored Bed Setting (Including the Intensive Care Unit)
  • Patients with Organ Failure and/or Systemic Inflammatory Response Syndrome (SIRS) Should Be Admitted to a Monitored Bed Setting
  • Scoring Systems and Imaging Alone are Not Accurate in Determining Which Patients with Acute Pancreatitis Will Develop Moderately-Severe or Severe Acute Pancreatitis
  • In Patients with Mild Acute Pancreatitis, Clinicians Should Be Vigilant for the Development of Organ Failure or Severe Acute Pancreatitis During the First 48 hrs of Admission

Address Source

  • Pancreatic Duct Obstruction-Related Acute Pancreatitis
    • ERCP or surgery may be required to relieve obstruction
  • Drug/Toxin-Related Acute Pancreatitis
    • Cessation of drug or toxic exposure (especially in ETOH-related cases)

Analgesia

Rationale

  • Abdominal Pain is a Frequent and Predominant Symptom in Acute Pancreatitis
  • Uncontrolled Pain Can Contribute to Hemodynamic Instability
    • Hypovolemia/Hemoconcentration May Contribute to Ischemic Pain and the Development of Lactic Acidosis

Intravenous Opioids (see Opioids)

  • General Comments
    • Intravenous Opioids are Safe and Effective for Analgesia in the Setting of Acute Pancreatitis (Cochrane Database Syst Rev, 2013) [MEDLINE]
    • Patient-Controlled Analgesia (PCA) May Be Required
  • Agents

(Cochrane Database Syst Rev, 2013) [MEDLINE]

Intravenous Fluid Resuscitation

Rationale

  • Intravenous Fluid Resuscitation is a Cornerstone of Acute Pancreatitis Treatment in the First 24-48 hrs
    • Intravenous Fluids are Required to Address the Following
      • Significant Third-Space Fluid Losses (Associated with Inflammatory Collections)
      • Increased Vascular Permeability (with Transudation of Fluid from Intravascular to Extravascular Spaces)
      • Nausea/Vomiting (with Inadequate Oral Fluid Replacement)

Type of Intravenous Fluid

  • Lactated Ringers (LR) (see Lactated Ringers)
    • Lactated Ringers Can Decrease the Incidence of Systemic Inflammatory Response Syndrome (SIRS) in the Setting of Acute Pancreatitis and May Decrease Hospital Length of Stay and Decrease the Intensive Care Unit (ICU) Admission Rate (Clin Gastroenterol Hepatol, 2011) [MEDLINE] (United European Gastroenterol J, 2018) [MEDLINE] (Pancreatology, 2018) [MEDLINE] (Gastroenterology, 2021) [MEDLINE] (Am J Gastroenterol, 2024) [MEDLINE]
      • However, Further Studies are Needed
    • Lactated Ringers is Contraindicated in the Setting of Hypercalcemia (Due to Lactated Ringers Containing a Calcium Concentration of 3 mEq/L)
  • Normal Saline (NS) (see Normal Saline)
  • Hydroxyethyl Starch
    • Contraindicated, Due to the Lack of Mortality Benefit and the Risk of Organ Failure (World J Gastroenterol, 2013) [MEDLINE] (Gastroenterology, 2018) [MEDLINE]

Rate of Intravenous Fluid Resuscitation

  • General Recommendation is for Approximately 1.5 mL/kg/hr with a 10 mL/kg Bolus for Hypovolemia) (Gastroenterology, 2018) [MEDLINE] (Am J Gastroenterol, 2024) [MEDLINE]
    • Moderation of Fluid Resuscitation May Be Considered in Patients with Underlying Cardiac/Renal Disease
  • Goal-Directed Fluid Resuscitation Should Be Based on the Following Factors (Clin Gastroenterol Hepatol, 2010) [MEDLINE] (Clin Gastroenterol Hepatol, 2011) [MEDLINE] (Pancreatology, 2013) [MEDLINE]
    • Heart Rate: goal heart rate <120 beats/min
    • Blood Pressure: goal mean arterial pressure 65-85 mm Hg
    • Blood Urea Nitrogen (BUN): goal reduction (especially if increased at hospital admission)
      • In a Large Hospital-Based Cohort, Increased Blood Urea Nitrogen (BUN) was the Most Reliable Laboratory Indicator to Predict the Mortality Rate in Severe Acute Pancreatitis (Gastroenterology, 2009) [MEDLINE]
        • For Every Increase in BUN of 5 mg/dL During the First 24 hrs, the Adjusted Odds Ratio for Mortality was 2.2
      • Another Study (n = 1,043) Demonstrated that BUN ≥20 mg/dL at Admission was Associated with an Increased Mortality Rate, as Compared to a BUN <20 mg/dL (Odds Ratio 4.6) (Arch Intern Med, 2011) [MEDLINE]
        • Additionally, Any Increase in BUN at 24 hrs was Associated with an Increased Mortality Rate (Odds Ratio 4.3)
    • Creatinine: goal reduction (especially if increased at hospital admission)
    • Urine Output: goal urine output >0.5-1.0 mL/kg/hr
    • Hematocrit: goal hematocrit 35-44%
  • While Intravenous Fluid Resuscitation is Critical in the First 24-48 hrs, Aggressive Intravenous Fluid Resuscitation Should Be Avoided After 48 hrs, Due to Risks of Respiratory Failure and Abdominal Compartment Syndrome

Clinical Efficacy-Need for Intravenous Fluid Resuscitation

  • Retrospective Studies Indicate that Initial Fluid Replacement (within 12-24 hrs) is Associated with Decreased Morbidity and Decreased Mortality Rates (Pancreatology, 2009) [MEDLINE] (Curr Gastroenterol Rep, 2011) [MEDLINE] (Pancreas, 2012) [MEDLINE] (Pancreatology, 2013) [MEDLINE]
  • Persistent Hemoconcentration at 24 hrs is Associated with the Development of Necrotizing Pancreatitis (Pancreatology, 2002) [MEDLINE]
  • Necrotizing Pancreatitis Results in Vascular Leak Syndrome Leading to Increased Third-Space Fluid Loss and Worsened Pancreatic Hypoperfusion (Am J Gastroenterol, 2010) [MEDLINE]

Clinical Efficacy-Optimal Timing/Rate/Duration and Type of Intravenous Fluid Resuscitation

  • In Systematic Reviews (n = 13,052 from 81 Studies), the Optimal Timing, Rate, Duration and Type of Intravenous Fluid Resuscitation Has Not Been Well Established (J Crit Care, 2014) [MEDLINE]
  • While Previous Guidelines Have Recommended 250-500 mL/hr of Normal Saline During the First 24-48 hrs, Evidence from Randomized, Controlled Trials Suggest that Lower Resuscitation Fluid Volumes May Be Utilized in the Setting of Mild Acute Pancreatitis (Pancreatology, 2013) [MEDLINE] (Am J Gastroenterol, 2013) [MEDLINE] (NEJM, 2016) [MEDLINE] (NEJM, 2022) [MEDLINE]
  • Multicenter, Randomized WATERFALL Trial of Aggressive (Lactated Ringer Bolus 20 mL/kg, Followed by 3 mL/kg/hr) vs Moderate (Lactate Rimgers 1.5 mL/kg/hr with a 10 mL/kg Bolus Only in Patients with Hypovolemia) Intravenous Fluid Resuscitation in Acute Pancreatitis (NEJM, 2022) [MEDLINE]: n = 249 (18 centers) No Difference in Incidence of Moderately Severe or Severe Pancreatitis or Duration of Hospitalization Between the Groups Trial was Terminated Early Due to Higher Rates of Fluid Overload in the Aggressive Resuscitation Group (20% vs 6%)
  • Systematic Review and Meta-Analysis of Aggressive vs Non-Aggressive Intravenous Fluid Resuscitation in Acute Pancreatitis (Crit Care, 2023) [MEDLINE]: n = 953 (from 9 randomized controlled trials)
    • As Compared to Non-Aggressive Intravenous Fluid Resuscitation, Aggressive Intravenous Fluid Resuscitation Significantly Increased Mortality Risk in Severe Acute Pancreatitis (Pooled Relative Risk: 2.45, 95% CI: 1.37, 4.40), While the Result in Non-Severe Acute Pancreatitis was Inconclusive (Pooled Relative Risk: 2.26; 95% CI: 0.54, 9.44)
    • Aggressive Intravenous Fluid Resuscitation Significantly Increased Fluid-Related Complication Risk in Both Severe (Pooled Relative Risk: 2.22; 95% CI 1.36, 3.63) and Non-Severe Acute Pancreatitis (Pooled Relative Risk: 3.25; 95% CI: 1.53, 6.93)
    • There were Worse APACHE II Scores (Pooled Mean Difference: 3.31; 95% CI: 1.79, 4.84) in Severe Acute Pancreatitis, and No Increased Likelihood of Clinical Improvement (Pooled Relative Risk: 1.20; 95% CI: 0.63, 2.29) in Non-Severe Acute Pancreatitis
    • Sensitivity Analyses Including Only Randomized Controlled Trials with Goal-Directed Fluid Therapy After Initial Intravenous Fluid Resuscitation Therapy Yielded Consistent Results

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Aggressive Intravenous Hydration (Defined as 250-500 ml/hr of Isotonic Crystalloid Solution) Should Be Provided to All Patients, Unless Cardiovascular and/or Renal Comorbidities Exist
    • Early Aggressive Intravenous Hydration is Most Beneficial in the First 12–24 hrs, and May Have Little Benefit Beyond that Period of Time (Strong Recommendation, Moderate Quality of Evidence)
  • In a Patient with Severe Volume Depletion, Manifest as Hypotension and Tachycardia, More Rapid Repletion (Bolus) May Be Required (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 hrs of Admission and for the Next 24–48 hrs
    • Goal of Aggressive Hydration Should Be to Decrease the Blood Urea Nitrogen (BUN) (Strong Recommendation, Moderate Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Moderately Aggressive Intravenous Fluid Resuscitation is Recommended in the Treatment of Acute Pancreatitis (Conditional Recommendation, Low Quality of Evidence)
    • Additional Intravenous Fluid Boluses May Be Required if There is Evidence of Hypovolemia
    • Caution Should Be Exercised in the Setting of Comorbid Cardiac or Renal Disease
    • Patients Should Be Monitored for the Development of Volume Overload
  • Intravenous Fluid Resuscitation in Acute Pancreatitis is Likely More Important Early in the Course of Disease (within the First 24 hrs)
  • Intravenous Fluid Volumes Should Be Monitored at Frequent Intervals within the First 6 hrs of Presentation and for the Next 24-48 hrs with the Goal to Decrease the Blood Urea Nitrogen (BUN)
  • Lactated Ringers (LR) Solution is Recommended Over Normal Saline for Intravenous Fluid Resuscitation in the Treatment of Acute Pancreatitis (Conditional Recommendation, Low Quality of Evidence)

Antibiotics

Clinical Efficacy

  • Systematic Review and Meta-Analysis of Prophylactic Carbapenem Antibiotics Administration in Severe Acute Pancreatitis (Digestion, 2022) [MEDLINE]
    • Seven articles comprised 5 randomized controlled trials and 2 retrospective observational studies, including 3,864 Severe Acute Pancreatitis participants
    • Prophylactic carbapenem antibiotics in Severe Acute Pancreatitis were associated with a statistically significant reduction in the incidence of infections (odds ratio [OR]: 0.27; p = 0.03) and complications (OR: 0.48; p = 0.009)
    • *Nevertheless, no statistically significant difference was demonstrated in the incidence of infected pancreatic or peripancreatic necrosis (OR: 0.74; p = 0.24), mortality (OR: 0.69; p = 0.17), extrapancreatic infection (OR: 0.64, p = 0.54), pulmonary infection (OR: 1.23; p = 0.69), blood infection (OR: 0.60; p = 0.35), urinary tract infection (OR: 0.97; p = 0.97), pancreatic pseudocyst (OR: 0.59; p = 0.28), fluid collection (OR: 0.91; p = 0.76), organ failure (OR: 0.63; p = 0.19), acute respiratory distress syndrome (OR: 0.80; p = 0.61), surgical intervention (OR: 0.97; p = 0.93), dialysis (OR: 2.34; p = 0.57), use of respirator or ventilator (OR: 1.90; p = 0.40), intensive care unit treatment (OR: 2.97; p = 0.18), and additional antibiotics (OR: 0.59; p = 0.28) between the experimental and control groups
    • It is not recommended to administer routine prophylactic carbapenem antibiotics in Severe Acute Pancreatitis

Recommendations (IAP/IPA Evidence-Based Guidelines for the Management of Acute Pancreatitis, 2013) (Pancreatology, 2013) [MEDLINE]

  • Prophylactic Antibiotics
    • Prophylactic Antimicrobials are Not Recommended for Severe Necrotizing Pancreatitis

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • Antibiotics for Extrapancreatic Infection
    • Antibiotics Should Be Given for an Extrapancreatic Infection, Such as Cholangitis, Catheter-Acquired Infection, Bacteremia, Urinary Tract Infection, and/or Pneumonia (Strong Recommendation, High Quality of Evidence)
  • Prophylactic Antibiotics
    • Routine Prophylactic Antibiotics in Patients with Severe Acute Pancreatitis are Not Recommended (Strong Recommendation, Moderate Quality of Evidence)
    • Use of Antibiotics in Patients with Sterile Necrosis to Prevent the Development of Infected Necrosis is Not Recommended (Strong Recommendation, Moderate Quality of Evidence)
  • Management of Suspected Infected Pancreatic Necrosis
    • Infected Necrosis Should Be Considered in Patients with Pancreatic or Extrapancreatic Necrosis Who Deteriorate or Fail to Improve After 7-10 Days of Hospitalization
    • Potential Strategies for Suspected Infected Pancreatic Necrosis (Strong Recommendation, Low Quality of Evidence)
      • Initial CT-Guided Fine Needle Aspiration for Gram Stain/Culture to Guide Antibiotic Therapy
      • Empiric Use of Antibiotics without CT-Guided Fine Needle Aspiration
    • In Patients with Infected Necrosis, Antibiotics Known to Penetrate Pancreatic Necrosis (Carbapenems, Quinolones, Metronidazole) May Be Useful in Delaying or Sometimes Totally Avoiding Intervention, Thus Decreasing Morbidity/Mortality (Conditional Recommendation, Low Quality of Evidence)
  • Use of Antifungal Agents
    • Routine Administration of Antifungal Agents Along with Prophylactic or Therapeutic Antibiotics is Not Recommended (Conditional Recommendation, Low Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients with Severe Acute Pancreatitis, Prophylactic Antibiotics are Not Recommended (Conditional Recommendation, Very Low Quality of Evidence)
  • While Antibiotics Should Not Be Used in Patients with Sterile Necrosis, Antibiotics (with Debirdement/Necrosecotmy) are an Important Components of Treatment for Infected Necrosis*
  • In Patients with Infected Necrosis, Antibiotics Known to Penetrate Infected Necrosis are Recommended to Delay Surgical/Endosacopic/Interventional Radiologic Drainage Beyond 4 wks
    • Some Patients May Avoid Drainage Altogether Because the Infection May Completely resolve with Antibiotics
  • Routine Administration of Antifungal Agents Along with Prophylactic or Therapeutic Antibiotics is Not Necessary

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients with Severe Acute Pancreatitis, Prophylactic Antibiotics are Not Recommended (Conditional Recommendation, Very Low Quality of Evidence)
  • While Antibiotics Should Not Be Used in Patients with Sterile Necrosis, Antibiotics (with Debirdement/Necrosecotmy) are an Important Components of Treatment for Infected Necrosis
  • In Patients with Infected Necrosis, Antibiotics Known to Penetrate Infected Necrosis are Recommended to Delay Surgical/Endosacopic/Interventional Radiologic Drainage Beyond 4 wks
    • Some Patients May Avoid Drainage Altogether Because the Infection May Completely resolve with Antibiotics
  • Routine Administration of Antifungal Agents Along with Prohylactic or Therapeutic Antibiotics is Not Necessary

Nutrition

Types of Nutritional Support

Clinical Efficacy

  • Meta-Analysis of Nasogastric vs Nasojejunal Feeding in Severe Acute Pancreatitis (Crit Care, 2013) [MEDLINE]: small study
    • Nasogastric Feeding is Safe and Well-Tolerated, as Compared to Nasojejunal Feeding
  • Dutch PYTHON Trial Comparing Early Enteral Nutrition with Oral Intake in Severe Acute Pancreatitis (NEJM, 2014) [MEDLINE]: n = 208
    • If Oral Intake was Inadequate in the Latter Oral Intake Group (“On-Demand” Group), Enteral Nutrition was Started
    • In Patients with Acute Pancreatitis at High Risk for Complications, Early Enteral Nutrition (within 24 hrs of Emergency Department Presentation) was Not Superior to Oral Intake (Started After 72 hrs), in Terms of Decreasing the Infection Rate or Mortality Rate within 6 mo
  • Systematic Review of Timing of Nutrition in Acute Pancreatitis (Ann Intern Med, 2017) [MEDLINE]: 11 trials (n = 948)
    • Mild-Moderate Pancreatitis: early feeding was associated with decreased length of stay in 4/7 studies (including 2/3 with low risk of bias)
      • Other Outcomes were Heterogeneous and Variably Reported, But No Study Demonstrated an Increased Risk of Adverse Events with Early Feeding
    • Severe Pancreatitis: limited evidence demonstrated no difference between early and delayed feeding

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • In Mild Acute Pancreatitis, Oral Feedings Can Be Started Immediately if There is No Nausea/Vomiting, and Abdominal Pain Has Resolved (Conditional Recommendation, Moderate Quality of Evidence)
  • In Mild Acute Pancreatitis, 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 Acute Pancreatitis, Enteral Nutrition is Recommended to Prevent Infectious Complications (Strong Recommendation, High Quality of Evidence)
    • 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)
  • Nasogastric Delivery and Nasojejunal Delivery of Enteral Feeding Appear Comparable in Efficacy and Safety (Strong Recommendation, Moderate Quality of Evidence)

Recommendations (Society of Critical Care Medicine/SCCM and American Society for Parenteral and Enteral Nutrition/ASPEN 2016 Guidelines) [MEDLINE]

  • Definitions
    • Mild Acute Pancreatitis
      • Absence of Organ Failure and Local Complications
    • Moderate Acute Pancreatitis
      • Transient Organ Failure (SBP <90 mm Hg, pO2/FIO2 Ratio ≤300, or AKI with Cr ≥1.9 mg/dL) Lasting <48 hrs with Presence of Local Complications (Pseudocyst, Abscess, Necrosis)
    • Severe Acute Pancreatitis
      • Persistent Organ Failure Lasting >48 hrs from Admission
  • Initial Nutritional Assessment Should Evaluate Disease Severity to Guide Nutritional Therapy (Expert Consensus)
    • Since Disease Severity May Change Quickly, Frequent Reassessment of Feeding Tolerance and the Need for Specialized Nutritional Therapy is Suggested
  • Mild Acute Pancreatitis
    • Oral Diet (Advanced As Tolerated) is Recommended (Quality of Evidence: Very Low)
    • If an Unexpected Complication Develops or There is a Failure to Advance Oral Diet within 7 Days, Specialized Nutritional Therapy Should Be Considered (Quality of Evidence: Very Low)
  • Moderate-Severe Acute Pancreatitis
    • Nasogastric tube Placement and Start of Trophic Tube Feedings with Advancement (As Tolerated) to Target Rate Within 24-48 hrs is Recommended (Quality of Evidence: Very Low)
    • If Intolerance Develops Occurs, the Following Measures Should Be Taken to Improve Tolerance (Expert Consensus)
      • Minimizing the Period of Ileus by Starting Enteral Nutrition as Soon as Possible within the First 48 hrs of Admission to the ICU
      • Diverting the Infusion of Enteral Feeding to a More Distal Gastrointestinal Tract Site (i.e. Jejunal Feeding): feeding into the jejunum is associated with a lesser degree of pancreatic stimulation, which increases the likelihood of the feedings being successful and circumvents the problem of gastric dysmotility
      • Changing from a Standard Polymeric Enteral Feeding Formula to One Which Contains Small Peptides and Medium Chain Triglycerides (MCT) or to One that is a Nearly Fat-Free Elemental Formulation
      • Switching from Bolus to Continuous Infusion of Enteral Feeding
  • Severe Acute Pancreatitis
    • Standard Polymeric Tube Feed Formulation is Recommended (Quality of Evidence: Very Low)
    • Enteral Nutrition is Recommended (by Gastric or Jejunal Route) Over Total Parenteral Nutrition (TPN) in Severe Pancreatitis (Quality of Evidence: Low)
    • No Difference Between Gastric or Jejunal Feeding with Regard to Tolerance or Clinical Outcome (Quality of Evidence: Low)
    • Probiotics Should Be Considered with Early Tube Feeding in Severe Pancreatitis (Quality of Evidence: Low)
    • When Enteral Nutrition is Not Possible, Parenteral Nutrition Can Be Considered After 1 Week From the Onset of the Acute Pancreatitis Episode (Expert Consensus)

Recommendations (American Gastroenterological Association Institute Guidelines for the Initial Management of Acute Pancreatitis, 2018) [MEDLINE]

  • Fluid Resuscitation
    • In Patients with Acute Pancreatitis, Goal-Directed Therapy for Fluid Management is Recommended (Conditional Recommendation, Very Low Quality of Evidence)
      • No Recommendation Whether Normal Saline or Lactated Ringers is Used
    • In Patients with Acute Pancreatitis, Hydroxyethyl Starch Fluids are Not Recommended (Conditional Recommendation, Very Low Quality of Evidence)
  • Antibiotics
    • In Patients with Predicted Severe Acute Pancreatitis and Necrotizing Acute Pancreatitis, Prophylactic Antibiotics are Not Recommended (Conditional Recommendation, Low Quality of Evidence)
  • Nutrition
    • In Patients with Acute Pancreatitis, Early Oral Feeding (within 24 hrs) is Recommended (as Tolerated) (Strong Recommendation, Moderate Quality of Evidence)
    • In Patients with Acute Pancreatitis and Inability to Feed Orally, Enteral Nutrition is Recommended Over Parenteral Nutrition (Strong Recommendation, Moderate Quality of Evidence)
    • In Patients with Predicted Severe or Necrotizing Pancreatitis Requiring Enteral Tube Feeding, Nasogastric or Nasojejunal Route is Recommended (Conditional Recommendation, Low Quality of Evidence)
  • Use of Endoscopic Retrograde Cholangiopancreatography (ERCP)
    • In Patients with Acute Biliary Pancreatitis and No Cholangitis, the Routine Use of Urgent Endoscopic Retrograde Cholangiopancreatography (ERCP) is Not Recommended (Conditional Recommendation, Low Quality of Evidence)
  • Use of Cholecystectomy
    • In Patients with Acute Biliary Pancreatitis, Cholecystectomy is Recommended During the Initial Admission Rather than After Discharge (Strong Recommendation, Moderate Quality of Evidence)
  • Use of Alcohol Intervention
    • In Patients with Acute Alcoholic Pancreatitis, Brief Alcohol Intervention is Recommended (Strong Recommendation, Moderate Quality of Evidence)

European Society for Clinical Nutrition and Metabolism (ESPEN) Guideline (Clin Nutr, 2020) [MEDLINE]

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Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • In Patients with Mild Acute Pancreatitis, Early (within 24-48 hrs) Oral Feeding is Recommended (as Tolerated), as Opposed to an NPO Approach (Conditional Recommendation, Low Quality of Evidence
  • In Patients with Mild Acute Pancreatitis, Initial Oral Feeding with Low-Fat Solid Diet is Recommended, as Opposed to a Stepwise Liquid to Solid Approach (Conditional Recommendation, Low Quality of Evidence
  • In Patients with Moderatrly-Severe or Severe Acute Pancreatitis, Enteral NUtrition Seems to Prevent Infectious Complications
  • Unless the Enteral Route is Impossible/Not Tolerated/Not Meeting Caloric Requirements, Total Parenteral Nutrition (TPN) Should Be Avoided
  • Using a Nasogastric (NG) Tube Rather than Nasojejunal (NJ) Tube for the Delivery of Enteral Feeding is Preferred Because of Comparable Safety and Efficacy

European Society for Clinical Nutrition and Metabolism (ESPEN) Practical Guidelines for Clinical Nutrition in Acute/Chronic Pancreatitis (Clin Nutr, 2024) [MEDLINE]

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Treatment of Hypertriglyceridemia in the Setting of Acute Pancreatitis (see Hypertriglyceridemia)

Clinical Efficacy

Respiratory Support

  • Mechanical Ventilation: as required

Surgery

Recommendations (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • In Patients with Mild Acute Pancreatitis, 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 Acute Pancreatitis, 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 extrapancreatic 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 liquefication of the contents and the development of a fibrous wall around the necrosis (walled-off necrosis) (strong recommendation, low quality of evidence)
  • In symptomatic patients with infected necrosis, minimally invasive methods of necrosectomy are preferred to open necrosectomy (Strong Recommendation, Low Quality of Evidence)

Recommendations (American College of Gastroenterology Guidelines: Management of Acute Pancreatitis, 2024) (Am J Gastroenterol, 2024) [MEDLINE]

  • Patients with Mild Acute Biliary Pancreatitis Should Undergo Cholecystectomy Early (Preferably Before Discharge)
  • In Stable Patients with Symptomatic Pancreatic Necrosis, Minimally-Invasive Methods are Preferred to Open Surgery for Debridement/Necrosectomy
  • In Stable Patients with Pancreatic Necrosis, Delaying Any Surgical/Endoscopic/Interventional Radiologic Intervention (Preferably to >4 wks) is Recommended to Allow the Wall of the Collection to Mature

Management of Pancreatic Pseudocyst

Axios Stent Drainage

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Prognosis

General Comments

  • Overall Mortality Rates in Acute Pancreatitis is 2%
    • However, Mortality Rate Can Be as High as 30% in Patients with Persistent Organ Failure (NEJM, 2016) [MEDLINE]
  • Between 1998 and 2003, Mortality Rate from Acute Pancreatitis Decreaased from 12% to 2% (Ann Epidemiol, 2007) [MEDLINE]
    • However, Mortality Rates Remain Far Higher in the Subgroup of Patients with Severe Acute Pancreatitis

Presence of Hemoconcentration

  • Presence of Hemoconcentration Has Variable Performance as a Predictor of Severe Acute Pancreatitis (Likely Due to Differences in the Cutoff Value Used and the Time that Values were Obtained in Studies) (Am J Gastroenterol, 1998) [MEDLINE] (Pancreas, 2000) [MEDLINE] (Am J Gastroenterol, 2001) [MEDLINE] (World J Gastroenterol, 2005) [MEDLINE] (Am J Gastroenterol, 2009) [MEDLINE]
  • In General, Normal or Low Hematocrit at Admission and During the First 24 hrs is Associated with a Milder Clinical Course

Presence of Increased Blood Urea Nitrogen (BUN) (see Increased Blood Urea Nitrogen)

  • In a Large Hospital-Based Cohort, Increased Blood Urea Nitrogen (BUN) was the Most Reliable Laboratory Indicator to Predict the Mortality Rate in Severe Acute Pancreatitis (Gastroenterology, 2009) [MEDLINE]
    • For Every Increase in BUN of 5 mg/dL During the First 24 hrs, the Adjusted Odds Ratio for Mortality was 2.2
  • Another Study (n = 1,043) Demonstrated that BUN ≥20 mg/dL at Admission was Associated with an Increased Mortality Rate, as Compared to a BUN <20 mg/dL (Odds Ratio 4.6) (Arch Intern Med, 2011) [MEDLINE]
    • Additionally, Any Increase in BUN at 24 hrs was Associated with an Increased Mortality Rate (Odds Ratio 4.3)

Presence of Increased Serum Creatinine (see Increased Serum Creatinine)

  • In a Study (n = 129), Peak Creatinine >1.8 mg/dL During the First 48 hrs Had a Positive Predictive Value of 93% for the Development of Pancreatic Necrosis (Am J Gastroenterol, 2009) [MEDLINE]
  • However, in a German Study, This Association was Not Observed, Although it Did Demonstrate that a Normal Serum Creatinine Had a High Negative Predictive Value for the Development of Pancreatic Necrosisbexx (Am J Gastroenterol, 2010) [MEDLINE] Authors Suggested that a Normal Serum Creatinine in the Absence of Complications Obviated the Need for an Abdominal Computed Tomographic (CT) Scan Importantly, This Study Had a Lower Prevalence of Pnacreatic Necrosis, Which Could Have Resulted in a Lower Positive Predictive Value

Acute Physiology and Chronic Health Examination (APACHE) II Score

  • Score <8 Predicts a Mortality Rate <4%, While Score >8 Predicts a Mortality Rate 11-18% (Am J Gastroenterol, 2006) [MEDLINE]

Scoring Paradigms

  • Ranson’s Criteria
  • Atlanta Classification (AC)
  • Revised Atlanta Classification (RAC)
  • Determinant-Based Classification (DBC)

Clinical Features (on Initial Risk Assessment) Which are Associated with Severe Course of Acute Pancreatitis (American College of Gastroenterology Practice Guidelines, 2013) (Am J Gastroenterol, 2013) [MEDLINE]

  • General Comments
    • Severe Acute Pancreatitis is Defined as the Presence of Organ Failure and/or Pancreatic Necrosis
  • Patient Characteristics
    • Age >55 y/o
    • Altered Mental Status
    • Comorbid Disease
    • Obesity (BMI >30kg/m2)
  • Systemic Inflammatory Response Syndrome (SIRS) Characteristics (>2 of the Following)
    • Heart Rate >90 bpm
    • Respiratory Rate >20/min or pCO2 >32mmHg
    • Temperature >38°C or <36°C
    • WBC Count >12k or <4k Cells/mm3 or >10% Bands)
  • Laboratory Characteristics
    • BUN >20 mg/dl
    • Rising BUN
    • Hematocrit >44%
    • Rising Hematocrit
    • Elevated Creatinine
  • Radiologic Characteristics
    • Pleural Effusions (within the First 24 hrs)
    • Pulmonary Infiltrates (within the First 24 hrs)
    • Multiple or Extensive Extrapancreatic Collections

Clinical Efficacy

  • Study Comparing the Atlanta Classification (AC), Revised Atlanta Classification (RAC), and the Determinant-Based Classification (DBC) in Determining Outcome in Acute Pancreatitis (Pancreas, 2016) [MEDLINE]: n = 338
    • Approximately 37% of Patients Had Persistent Multisystem Organ Failure (Lasting >48 hrs)
    • Approximately 11% of Patients Had Pancreatic Necrosis
    • Overall Mortality Rate: 4.1%
    • RAC and DBC were Comparable in Identifying Stratifying Disease Severity and Predicting Mortality and ICU Admission (and Both Outperformed the AC)
      • However, the Paucity of Patients (n = 2) in the Critical Category in the DBC Limited its Utility in this Study
    • Neither Scoring System Accounts for the Impact of Multisystem Organ Failure (Which was the Strongest Predictor of Mortality with OR 75.0; 95% CI: 13.7-410.6)

Risk of Future Pancreatic Cancer (see Pancreatic Cancer)

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  • Acute pancreatitis recurrences augment long-term pancreatic cancer risk. Am J Gastroenterol. Published online December 20, 2022. doi:10.14309/ajg.0000000000002081 [MEDLINE]
    • This retrospective study used nationwide Veterans Administration database spanning 1999-2015. A 2-year washout period was applied to exclude patients with preexisting acute pancreatitis and pancreatic ductal adenocarcinoma
    • pancreatic ductal adenocarcinoma risk was estimated in patients with acute pancreatitis without (acute pancreatitis group) and with underlying CP (APCP group) and those with chronic pancreatitis alone (chronic pancreatitis group) and compared with pancreatic ductal adenocarcinoma risk in patients in a control group, respectively, using cause-specific hazards model
    • Results
      • The final cohort comprised 7,147,859 subjects (acute pancreatitis-35,550 and pancreatic ductal adenocarcinoma-16,475)
      • The cumulative pancreatic ductal adenocarcinoma risk 3-10 years after acute pancreatitis was higher than in controls (0.61% vs 0.18%), adjusted hazard ratio (1.7 [1.4-2.0], P < 0.001)
      • Adjusted hazard ratio was 1.5 in acute pancreatitis group, 2.4 in the CP group, and 3.3 in acute pancreatitis with underlying chronic pancreatitis group
      • pancreatic ductal adenocarcinoma risk increased with the number of acute pancreatitis episodes
      • Elevated pancreatic ductal adenocarcinoma risk after AP was not influenced by the etiology of acute pancreatitis (gallstones, smoking, or alcohol)
    • There is a higher pancreatic ductal adenocarcinoma risk 3-10 years after acute pancreatitis irrespective of the etiology of acute pancreatitis, increases with the number of episodes of acute pancreatitis and is additive to higher pancreatic ductal adenocarcinoma risk because of chronic pancreatitis

References

General

Etiology

Physiology

Clinical Scoring of Acute Pancreatitis

Clinical Manifestations

Treatment

General

Intravenous Fluids

Antibiotics

Nutrition

Prognosis

General

Hemoconcentration

Increased Blood Urea Nitrogen (BUN) (see Increased Blood Urea Nitrogen)

Increased Serum Creatinine (see Increased Serum Creatinine)