Seminar

Acute pancreatitis
Lotte Boxhoorn, Rogier P Voermans, Stefan A Bouwense, Marco J Bruno, Robert C Verdonk, Marja A Boermeester, Hjalmar C van Santvoort*,
Marc G Besselink*

Lancet 2020; 396: 726–34 Acute pancreatitis is an unpredictable and potentially lethal disease. The prognosis mainly depends on the
*Joint senior authors development of organ failure and secondary infection of pancreatic or peripancreatic necrosis. In the past 10 years,
Department of treatment of acute pancreatitis has moved towards a multidisciplinary, tailored, and minimally invasive approach.
Gastroenterology and Despite improvements in treatment and critical care, severe acute pancreatitis is still associated with high mortality
Hepatology (L Boxhoorn MD, rates. In this Seminar, we outline the latest evidence on diagnostic and therapeutic strategies for acute pancreatitis.
R P Voermans MD) and
Department of Surgery
(Prof M A Boermeester MD, Introduction limit of normal, or (3) findings consistent with acute
Prof M G Besselink MD), Acute pancreatitis is the most common gastrointestinal pancreatitis on imaging (contrast-enhanced CT [CECT],
Amsterdam Gastroenterology
disease requiring acute admission to hospital, with an MRI, or abdominal ultrasound; figure 1).7,8 If typical
Endocrinology Metabolism,
Amsterdam UMC, University of annual inci­dence of 34 per 100 000 person-years in high- clinical and laboratory findings are present, additional
Amsterdam, Amsterdam, income countries.1 The disease is characterised by a local imaging is not required to confirm the diagnosis of
Netherlands; Department of and systemic inflammatory response and has a varying acute pancreatitis. Nonetheless, imaging can be
Surgery, Maastricht University
clinical course. Most patients present with mild acute indicated in the early phase when there is diagnostic
Medical Center+, Maastricht,
Netherlands pancreatitis, which is self-limiting and usually resolves uncertainty. Necrotising pancreatitis can commonly
(S A Bouwense MD); within 1 week. Approximately 20% of patients develop only be detected on imaging from 72 to 96 h after onset
Department of moderate or severe acute pancreatitis, with necrosis of the of symptoms.7
Gastroenterology and
pancreatic or peripancreatic tissue or organ failure, or
Hepatology, Erasmus
University Medical Center, both, and a substantial mortality rate of 20–40%.2–5 Aetiology
Rotterdam, Netherlands Treatment of acute pancreatitis has undergone Current guidelines recommend identification of the
(Prof M J Bruno MD); considerable changes in the past 10 years—ie, the causes of the disease as early as possible.7 Gallstones (45%)
Department of
introduction of a multidis­ ciplinary, tailored approach and alcohol abuse (20%) are the most frequent causes of
Gastroenterology and
Hepatology (R C Verdonk MD) including minimally invasive endoscopic, radiological, acute pancreatitis in most high-income countries.9
and Department of Surgery and surgical interventions for infected pancreatic and The least common causes are medication, endoscopic
(Prof H C van Santvoort MD), peripancreatic necrosis and improvements in critical retrograde cholangiopancreatography (ERCP), hypercal­
St Antonius Hospital,
Nieuwegein, Netherlands;
care have reduced both morbidity and mortality.6 This caemia, hypertriglyceridaemia, infection, genetics, auto­
and Department of Surgery, Seminar provides an over­view of current evidence on immune diseases, and (surgical) trauma. Standard initial
University Medical Center the diagnosis, classification, and treatment of acute diagnostic testing of acute pancreatitis include evaluation
Utrecht, Utrecht, Netherlands pancreatitis, and addresses new developments and of medical history (eg, alcohol intake and medication,
(Prof H C van Santvoort)
unanswered research questions. family history, and known gallstone disease), physical
Correspondence to:
examination, laboratory tests (eg, liver enzymes, serum
Prof Marc G Besselink,
Department of Surgery, Diagnosis and aetiology triglycerides, and calcium), and transabdominal ultra­
Amsterdam Gastroenterology Clinical presentation sound. If no causal factor is identified by these initial
Endocrinology Metabolism, Patients with acute pancreatitis commonly present with tests, an extensive evaluation is indicated to reduce the
Dutch Pancreatitis Study Group,
Amsterdam UMC, University of
severe upper abdominal pain. The diagnosis of acute risk of disease recurrence.
Amsterdam, pancreatitis is based on the fulfilment of two of three
Amsterdam 1100 DD, criteria: (1) upper abdominal pain, (2) serum amylase Prediction of severity
Netherlands or lipase (or both) of at least three times the upper Given the unpredictable course of acute pancreatitis, it is
m.g.besselink@
amsterdamumc.nl
not surprising that a plethora of studies has attempted
to predict the clinical course of the disease. Clinical
Search strategy and selection criteria and biochemical scoring systems include the Acute
The most recent international evidence-based guidelines on Physiology and Chronic Health Evaluation II, Ranson’s
acute pancreatitis were used as the main source for this Criteria for Pancreatitis Mortality or Modified Glasgow
Seminar. An additional systematic literature search done on Acute Pancreatitis Severity Score, and individual serum
July 1, 2019, in the Cochrane Library, PubMed, and Embase tests (ie, C-reactive protein and blood urea nitrogen).10,11
databases, focused on studies published after the 2013 The scoring systems are frequently used for research
International Association of Pancreatology and American pur­poses, but are without clinical relevance because of
Pancreatic Association guidelines were released. We used the their low predictive value.12
search terms “acute pancreatitis” and “necrotising Current guidelines recommend monitoring the
pancreatitis”, and selected publications from the past 5 years, presence of systemic inflammatory response syndrome
but did not exclude commonly referenced and relevant older or organ failure at admission for a minimum of 48 h
publications or guidelines. to predict the development of a severe course of the
disease.7,13

726 www.thelancet.com Vol 396 September 5, 2020

The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6
The Lancet, 396 (2020) 726-734. doi:10.1016/S0140-6736(20)31310-6