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Piis0016508507005926 PDF
Piis0016508507005926 PDF
This document presents the official recommendations of the American Gastroenterological Association (AGA) Institute on
Management of Acute Pancreatitis. It was approved by the Clinical Practice and Economics Committee on February 14, 2007,
and by the AGA Institute Governing Board on March 15, 2007.
This fact means that there remain today differences in best achieved by careful ongoing clinical assessment
opinion from center to center and country to country coupled with the use of a multiple factor scoring
about the proper management of patients with acute system and imaging studies. The Acute Physiology
pancreatitis. This has led in the past to several practice and Chronic Health Evaluation (APACHE) II system
guidelines from various national and international pro- is preferred, utilizing a cutoff of 8. Those with
predicted or actual severe disease, and those with
fessional societies that differ in their specific recommen-
dations. These AGA Institute guidelines have been devel-
oped to guide clinicians in the management of patients 2007 by the AGA Institute
0016-5085/07/$32.00
with both mild and severe acute pancreatitis. doi:10.1053/j.gastro.2007.03.066
2020 AGA INSTITUTE GASTROENTEROLOGY Vol. 132, No. 5
other severe comorbid medical conditions, should be cholangiopancreatography (ERCP) should be con-
strongly considered for triage to an intensive care sidered. EUS is preferred as the initial test. If ERCP
unit or intermediate medical care unit. is undertaken in this setting, it should be performed
by an endoscopist with the training, experience, and
Rapid-bolus contrast-enhanced CT should be per-
facilities to provide endoscopic therapy (including
formed after 72 hours of illness to assess the degree
minor papilla sphincterotomy and pancreatic duct
of pancreatic necrosis in patients with predicted
stent placement) and sphincter of Oddi manometry,
severe disease (APACHE II score 8) and in those
if required. Genetic testing is not currently recom-
with evidence of organ failure during the initial 72
mended as part of the initial workup but may be
hours. CT should be used selectively based on clin-
considered in selected patients.
ical features in those patients not satisfying these
criteria. Management
Laboratory tests may be used as an adjunct to General supportive care, consisting of vigorous fluid
clinical judgment, multiple factor scoring systems, resuscitation, supplemental oxygen as required, cor-
and CT to guide clinical triage decisions. A serum rection of electrolyte and metabolic abnormalities,
C-reactive protein level 150 mg/L at 48 hours and pain control, must be provided to all patients.
after disease onset is preferred. Nutritional support should be provided in those
patients likely to remain nothing by mouth for
Determination of Etiology
more than 7 days. Nasojejunal tube feeding, using an
The etiology of acute pancreatitis should be able to elemental or semielemental formula, is preferred
be established in at least three fourths of patients. over total parenteral nutrition. Total parenteral nu-
The initial history should particularly focus on pre- trition should be used in those unable to tolerate
vious symptoms or documentation of gallstones, enteral nutrition.
alcohol use, history of hypertriglyceridemia or hy-
Gallstone pancreatitis. Urgent ERCP (within 24
percalcemia, family history of pancreatic disease,
hours) should be performed in patients with gall-
prescription and nonprescription drug history, his-
stone pancreatitis who have concomitant cholangi-
tory of trauma, and the presence of concomitant
tis. Early ERCP (within 72 hours) should be per-
autoimmune diseases.
formed in those with a high suspicion of a persistent
At admission, all patients should have serum ob- common bile duct stone (visible common bile duct
tained for measurement of amylase or lipase level, stone on noninvasive imaging, persistently dilated
triglyceride level, calcium level, and liver chemistries common bile duct, jaundice). Endoscopic sphincter-
(bilirubin, aspartate aminotransferase, alanine ami- otomy in the absence of choledocholithiasis at the
notransferase, and alkaline phosphatase). If triglyc- time of the procedure is a reasonable therapeutic
eride levels cannot be obtained at admission, fasting option, but data supporting this practice are lacking.
triglyceride levels should be measured after recovery Early ERCP in those with predicted or actual severe
when the patient has resumed normal intake. gallstone pancreatitis in the absence of cholangitis
or a high suspicion of a persistent common bile duct
Abdominal ultrasonography should be obtained at
stone is controversial, and endorsement of this prac-
admission to look for cholelithiasis or choledocho-
tice varies from center to center and country to
lithiasis. If the initial ultrasound examination is in-
country. In those unfit for surgery, ERCP and
adequate or if a suspicion of gallstone pancreatitis is
sphincterotomy alone provides adequate long-term
still present, repeat ultrasonography after recovery
therapy. In all others with gallbladder in situ, defin-
should be performed. Endoscopic ultrasonography
itive surgical management (cholecystectomy) should
(EUS) can be used as an accurate alternative ap-
be performed in the same hospital admission if pos-
proach to screen for cholelithiasis and choledocho-
sible and, otherwise, no later than 2 4 weeks after
lithiasis, either at admission or thereafter.
INSTITUTE
discharge.
AGA
the efficacy of antibiotic prophylaxis to prevent con- Role of surgery in acute pancreatitis. Surgery has
version of sterile necrosis to infected necrosis are no role in mild acute pancreatitis or in severe pan-
mixed and difficult to interpret; no recommendation creatitis with sterile necrosis. Surgical therapy in
can be made at this time. Antibiotic prophylaxis, if infected necrosis can be considered, based on the
used, should be restricted to patients with substan- availability of other therapeutic options and the
tial pancreatic necrosis (30% of the gland necrotic consistency of the necrotic material.
by CT criteria) and should continue for no more
Prevention of recurrences. Those with alcoholic pan-
than 14 days. The development of infected necrosis
creatitis should be referred to counseling services and
should be suspected in those patients with preexist-
smoking cessation services, if applicable. Patients with
ing sterile pancreatic necrosis who have persistent or
gallstone pancreatitis should undergo prompt chole-
worsening symptoms or symptoms and signs of in-
cystectomy and/or endoscopic sphincterotomy, de-
fection, typically after 710 days of illness. In these
pending on their overall medical condition.
patients, fine-needle aspiration guided by CT imag-
ing should be performed and the sample should be Prevention of post-ERCP pancreatitis. ERCP
cultured and Gram stained to document infection. should be avoided if alternative diagnostic tests (in
Antibiotic therapy should be tailored based on the particular, CT, magnetic resonance cholangiopan-
results of fine-needle aspiration. The management creatography, or EUS) can provide similar diagnostic
of infected necrosis depends on how acutely ill the information. ERCP should be performed by endos-
patient is, the response to antibiotics, the consis- copists with appropriate training and experience.
tency of the necrotic material, and the local exper- Informed consent must provide the patient with a
tise in surgical and nonsurgical management of realistic assessment of both risk and expected bene-
necrosis. If possible, patients with infected necro- fit. Endoscopists performing ERCP should have the
sis should be managed in centers with specialist technical skill and familiarity to place pancreatic
units with appropriate endoscopic, radiologic, and duct stents in situations of high risk for post-ERCP
surgical expertise. pancreatitis.
Management of fluid collections and pseudo-
cysts. Acute fluid collections around the pancreas in Reference
the setting of acute pancreatitis require no therapy 1. Forsmark CE, Baillie J. AGA Institute Technical Review on acute
pancreatitis. Gastroenterology 2007;132:20222044.
in the absence of infection or obstruction of a sur-
rounding hollow viscus. Symptomatic, mature, en-
capsulated pseudocysts should be managed based on Address requests for reprints to: Chair, Clinical Practice and Eco-
local expertise with endoscopic, percutaneous, or nomics Committee, AGA Institute, c/o Membership Department, 4930
surgical techniques. Del Ray Avenue, Bethesda, Maryland 20814. Fax: (301) 654-5920.
INSTITUTE
AGA