JAMA | Review Acute Pancreatitis AReview MlcalA. Neder MO: Howard Reba MO: Ma. Gra MD Matin I Featedanctepage 39) Supplementalcontent IMPORTANCE IntheUnitedStates acute pancreatitis sone ofthe ladng causes of hospital admission from gastroincesinalcseases, ith approximately 300 000 emergency Acute pancreatitis i classified a 2 subtypes: interstitial edematous pancreattis and necrotizing pancreatitis (80x 2A). Interstitial edematous pacretit characterized by inflammation and edema of the pancreatic parenchyma ane peripancreatic tis ‘ses Necrotizing pancreaitis occurs when this process progresses to pancreatic or peripancreatic tssue death, Both forms of acute ‘ancteatsmay be assocated with the ca campications of pan- ‘ceatcfuidand said collections. Aciteperipancrestic id calc tins (APFCS) develop within weeks of disease onset and contan ‘most fice acuteneoti collections (ANCS) develop in necoti- Ing pancreatts and contain sold andilud components. Acute ‘ntraparcreaccolectors are aresult of nacrotizng parcrenies ‘and are refere toas ANCS APFCs and ANCS that pers after ‘weeks from orset of disease ae referred 102s peudocysts and walled ff recrosis. espectively (Box 2A and Figure) espanere atc and pancreatic cellectons may besecondariy infected ard JAMA san 22001 Veh 25 Number (©2021 American Medical Association. llrightsreserved.Clinical Review & Education Review Acate Pancreat: AReview 'Bor2 evsed arta assieatonDefiations ‘A. Morpolegi lassen of Aste Pancreas Inertial Edeste Parerostie se orcad evlrgement cf the pacress wih homogenous enfancementofthepaneat parenchyma Infmnatory tangs ofthe perianceate fat Peipancraticuid(seColectons below) “tuk APC ‘Adjcento the pznceas (0 irtraanceaticextnsion) Sing ormtphe Homogesousolectien with id ensty Noassocateé perparcresticnerss Connect rorma facial lanes ale Preworst atereencapsulstedcoletions)f fad wth 2 weldeined wal eusidethe pancreas Homogenoustuid deity Nosolid component Necoting anceattis Necrosis often invoking boththe pane parenchyna andperparcenctisue Varablecortrasentancement pattern inte fst fw cays "Nonentancng eas shou be conserednecoss ater the es wou ofeeeaco Moy become secondriyinfeted Goleciors che ANC described asinfecied ANCandinfected walle-off across. nad tion to pancreatic clletiors, local complications als include gastric outlet dysfunction, splenic or portal ein thrombosis ard cobnic ness” Clinical Presentation and agnosie ‘Abdominal painisthe mos: common xesentingsymotom. The pain Isusualy described asconstart and often withraiationtotheback that may be exacerbated by eating, inking or ving supine Accomparying symptomsoftenirclude nausea, vomiting andlow: tomocerate-grade fever. evaluation suspected acute pancret tisbegins witha comprehensive istry and physical examination. ‘Assesment shoul focuson histryof episodes of acute pancre attisand sk factors. cluding bilarycoegzltone disease aco holuse.famiyhistoryofacuteor chronic pancreas recentinfe- tions, vauma,insectbites,andnewmedications. Thisocusedhistoy canasistn identfying the underying etiology Physical examinatonofteneveasabdominal distention andde- creased bowel souncs. Rebound tenderness uncommon. Stan datdchemstes wthamyase, lipase ancliver peneltestscanhelp confirm the dagnosis of acute pancreatitis os wall s identity un desying etiology le. hypercalcemia) An elevated det bilrubin andjoraiclinephosptatavelevelmayindcatetheoresenceofagal- {AWA Janay 26,2021 Volume 25 Numbers Invlves the pancraticparerchyna or perpncreatitsies Heteregenous nd noni denstyof varying degrees in ‘ferent keaton WON ature ercapaatedcleconof puneretc andor perpen necrosis witha wel- defined wall Hetergereous wit id nd ronquid density with ary ingdegeesofbcutions 8 Dignan citeta or) 1 Abdomina'poin corsistent wth cute pocrestils 2. Ebvated serum amlase or Ipase>3 mes the upper it cofnornal 2. Characteritic cigs of ait anceatisonimegng (Ge contrat enharcedconputed tenopapy. magi eo ‘ranceimaging and les requert ras) adeno everty ta 1 Noorganfire 2, Noloal orsystemiconplitions Morro Severe 1. Ogantatize tat esohes wthin 48h (tansent eg fie) rox 2. Lecaler temic cempicatons without ersten orn fire 1 Pesisent gn fiure>48h) Sgleorgnfalure Mate onaniatre ‘broatans ANC. seermcotcleonAPF ae pepe id stoneinthecommontileduct ie, choledochothisis)orthatastone recently passed, Additional testing with transabdominal uta soundto ealiatetorgalstones ad serum riglycerdelevelsshoud _akobe obiained.gGalevels re spt wienautoinmmune pance ‘tts suspected Computed tomography (CT) or magnetic reso ranceimaging (MRI) may be inccated to evaluate for structural ‘causesof acute pancreas but hisisnot mandztoryduringinital management of the dsease process. Patients with ecurtentacute pancreatiso fail history of acute pancretits/chronc pancre: attiswithoutan identifiable etiology withthe aforementioned abs ‘orimagin shouldbe referredorgenetictestng to evaluate ore reditay pancreas Te diagnese acute pancreas, the revised Atlanta classifi: tion (PAC) requires 2 of the 3 folowing criteria be present: (2. ‘demiral pain suggestive of pancreas. 2) serum amylase andor lipasegreaterthan3tmes the upper imi of normal (2)andcross sectional imaging (CT or MR findings consent with acute pa retits (Box 28): Acute pancreatitis cn be dagnosed in about 80% of patients based on te presence of abdominal pain and et ‘vated pancreaticensymes only." However, CT 6 ausetl adjunct toconfirmacute panceattiswhen the dggnossisinquestionand torule out other intra abdominal conditions that can mimic acite pancreas such a perforated duodenal ulcer. {© 2021 Amorican Mackoat Association. Al rights rorerved.‘Acate Pancreatitis: A Review ‘Review Cinical Review & Education Figure Tinie Manfestatons. and Management Acute Parents oS He a i =) == == 1 )] Ge) ES : aera q ‘Golecytectony fr galstone pancreatitis pitt discharge (preerably within 24-88 0) g [Leitner ait ornasomteatentrton i en a | esas I a * ty CTox fine-needle aspiration Sane SE ase =e eben iit ae saree = E —— 325 ;§ —a— ae es — a SS ee ceca KeierGeoneranm) gid sid 3438193637498 tesa ee ae a a ements 2 as cane es ices chr The RAC graces acute panceattssevery by te pesenceand- ation of organ ature Ge, respatory. kidney, ane carcovasculr as determined by te modified Marshallscorng sytem: Table and the presence ofocd cmplcations. Patients wehout lacalcomp- cations of organ fllre ave mild cite poncrectts Patients with ‘ransientorgn flue (ecevery within 48 hour) andrlocal com: plications have moderetaly over aito pancreas, and patents wah porcstent rganfalure bayond 48 hour with or ithout oad completions havesovere acute pancoaii(Bx 20) Mildpancre- atts s the most common form of acute pancreatitis and issel- litre patintsaretypicaly discharged withnawek. Patients ith moderately severe andsaverecseiseoftenhavea protracted curse ‘over weeks to months due toloca complications and organ dys: function (Figure ‘Gven the variable lial coursein cute pancreattsand the ‘ipificant mortality teinsavere cases sever riskscoreshavebeen ‘developed to predict outcome (Table 2). These clssication ys temsmayasistn determining the apprepratelevelofcare(iten- sive care unt {ICU] vs non-ICU) and gude anticipatory manage: Useful agunets for decision-making in acute pancreattl, scoring ‘ops shouidnotreplace circa judgment. Me earlestscoring y+ ‘tem was published by Rarson et ”?*in 1974 and 1977 and a ‘ter by ree ain 1978 and 1984. However, botho these searing sytemsrecuire informaton sequired inthe fest 48 hours ‘ofhosptl presentation ard arecumbersomete caluste In 985, tho APACHEII mode” was developed aca comprehonsvetool de slgned to predict disease severity and rota inpatints admit tesdtotheICU APACHE IIrequiest2 variables Tablo2)thst arent reutinelyobsained inpatients who arenotcitcallyill Aditionally theBedside index fr Seveityin Acute Pancreatitis BISAP) score” was developed in 2008 and designed 25a predictor of mortality based on5 variables: ood urea nitrogen (BUN lev! greaterthan 25 mg/d, impaired mental status systemic inflammatory re- sponse syncrome (SIRS) age older than 60 eas, or adigraphic exidenceof plevaleffsion within the frst24 hous of admission. ‘The lowest core was associated withalssthar 186 rrtalty rate and the ighast witha greaterthan 20%mortalty ate Inadétion tomotalty ear tudes demonstrated aBISAP scoreo 3ergreater JAMA, Jam7/26 2021 Yoke 25,Nunbers (© 2921 Amorican Modcal Association. Al ights served.{Tae 2 Conpatsa of APACHE I BISAP and Ranson Scares Based oe Revised Alara Gasaficaion DUMWIOTS OT See om HSA? 2008, Gat). Rawson Vober he 1 BUN>25 mG. OBO TTL) Aas: Tenowatre “mses mets stne wines 1 ante presi ssaiRsentna {Wceourt>16 000). on tigers Mr ate Trt ttaionprent S esptorate Sn Teeseaetetos meg ‘ioee>6t gin pupae Sewrityotdseae ameraty eet ofnorbyin Prediction of mextaty in AP inte petens Prtichon srry, AWE GOP? + 05200) Scores +6800) 20871016) Prion of seer? Soe Sore23 Sere Pensanty ON) 31077080) Sos1042-960, Fe66(0.2.072) Spectciy (3%) Sossas608) s051(085039) $078(0-7-081) Prtcton fray, UC(SEY? + 083(0.19 Score23 #092005) SCs oo» Pedicon of moray?” scot sores scores Sst (O50) 95 (077-100 RG2RI8 £05310.7-.099) spect BO) $0858(0.63-0173 tot {03059 269(0.6.079) avanages sCanbecatatted win 26m «5 Vites + Comprehensive eae toate (1 poi Leche bervarnbie) ‘Soatcto a> Linitatons + Designed forpatietsadmited Lovers and specifcty = Ales hole xore toi Forpreactng goca seventy © Leta pants net cotecte retely Livgett of mindatoryvarbi; hah ABC ‘non-e ptients 5 NetSpec tO ‘Abrevtions: AP acute panceaitisAPACHEI, cute Psy and Gene Heath akaton lA aprtarearinorarsfrse: AUC are under cuve 1A. edie indovof Sever Astor DUN, aod reopen, Fi acto of nepled ange CU, erive cr unt Po, paral presse oer ong: iS stem nianmsto respore sndrome: was associated with developing organ faire (odds ratio [OR).74 [95% Cl, 2819.5), persistent organ fire (OR, 12.7[9596CI, 47- 339) and pancreaticnecrosis (OR, 38{9596CI, 18-8 5) BISAP 's widely used because ofits simplicity and ease of calculation (rable) Inadlton to scorirg systems, incvidualbiomarkers may also have predetive valueinacute pancreatitis C-reactiveprotein(CRP) {s commonly obtained in hospitalized patients. CRP levels of 190 mg/L or geater within the fist 48 hours of admission or an abso: lute increase of greater than 90 mg/Lhave positive predictive val ‘vor of 96.1% and 95.6% for proccting cover disco. espoctva.2° Radiologie seoringsystems, such as the CT Sevetity Index, may also be useful to accurately dagrose the extent and severity of pancreatitis"? However imaging:cores arent liable when scans are obsained at the ime of admission because contiast enhanced (CT may underestimate cr incorrectly dassify disease severity ifitis ‘obiained less than 72 hours after symptom onset “°° There fore, CTistecommended later in the disease couseto fully recog: nize the extent of disease processin patients with moderately se- vere or severe acutepancretis. ‘Management Overview of Management ‘There ae 2cormesstonesin acute pancreattis management, eg3rd- less ofthe etiology () fidresusckation to maintainorestoretis: JAMA Janary26 2021 Vue 325 Number sve perfusion and (2) nutritonal support to counter the catabolic state and decrease the rate of infectious complications, Flud Resuscitation Inuavescular volume depletion from fluid sequestation assoc ated with pancreatic peripancteatc, and systemic edemaschar- acteristic of patients withacute pancreatitis, Vortng, reduced oral intake, and peripancreatic inflammation contribute to fluid dei {ts The diminished crculating volume leads todecreasedtssue per fusion andmoy result multorgan ike. ntavascuarvlumesta tuscan be estimated by observing vital signs and meacuring urine output, BUN, and hematecrit. A low intravascular volume in- creases complications and mortality rate. For example, ina cudy of ‘5819 patients withacutepancreatits everyS.meldLincreasein BUN level within the fest 24 hours of admission was associated with an increased OR for mortality by2.2(95%CI, 19-29) Another study (of1043 patients withacutepancreatitisfoundanasscciatonof hos- pital mortality inpatients with an admission BUN level greater than 2Omeldt (OR, 45 (9596 C1,2.5-8.3)., andany rie in BUN level 26 hous aftes admission was associated wth an OR of 4:3 (959%CI,23- 79) for death Thus, mostsccring systems used inacute pancre- atts incorporatea marr of vlume status (Table 2 ‘The clinical guidelines for fhidresusctaton from anumber of expert groupsagree tha intravencus volumeresuscitatonshould be initiated as soon asthe dagnoss of acute parcretitsis made, Jmacom © 2021 American Medical Association, Al rights reserved.Talie3 Conpaison of Gulelnesfor Fad Resusdaton Natton, and Ting of Cholecystectomy Rijs Pocreni Tsk Quilyimgroymert Bert ecommenitin __wringnrazo.)” 1cn.2019" Feceontaay (019 Pana Oy To serge Mote ql IRE ‘even msity evens —Hndent auity cides Quay of eidace ewer ya Gos directed inirovenous fluid Goal-diracted therapyfor Bolus and maintenancefluid 23 mL/Ag/?, shouldbe initisted fesscoton —Shenpymih 10 raat Si asngenen ‘Scdatbewmvsion Sal phiie omobstes Neate 20h monte Nenconmednionenae, Seretoitend GRAIG hater ‘utput 20 rs nema ‘nine output, BUN, and ‘Trend BUN, hematocrit, Suit 0°51 nd fa/h nent, Shae ah Nereconmendten onrate rene ver Be ior te fra eae Tycoftutorintt Mode alivefedence —awulty dene Mndenteguaty ede Quilted ao Lactated Rieger ‘olution ‘No recommendation Lactated Ringer solution Ladtated Ringer soletion vaistontadcted Tinigotenen — Motes qwivofeidece ——NodetequlyHfeidece Hohalyolentene —Qulyotendence:8* nin Inmaicaledngscane _tatymulonwningen win 48-72 uss tsa IneaA? al ang ‘tame ce Nona a Miseecetonraniied aaa se 24 eting tonnes ieeelsotrectenee tampon cael Sapo sees Reed nscene Hi ay viene Uow-gattyoidncs—— Nogeteormcas® — Qubtyf oc tastier meio tcp rnminalor acibaetitn or ‘nonwna meeltsewree Srci iguana Titotnation Mote qalyotevice—_Rorcermendthn ——_‘Wohgilyeddece——_Woreconmedion Elenco pte lowed et ‘sr eenaos Tirso {ove aiyennce ageatequityensene — Hpheityendexe Quit eaexe's* _slecstectom for init amisionformHGAP ‘tia aarission “surgery consutation to ‘thin 2 wh for mild AP er Lovequltyeee care lest Chaecystectomy in biliary AP eee vilatedby “Moderate quaity evidence ‘orpbteay let tu {hy pest deend Swe ‘breton ACG. Arcs Coles of Casters: AGA Asan Gastoetersogcal Ssouaton, A atepacrests: APA Aneran ofPaeretdogy " Coteytctony ny AP motte brnevoss or Eclstons shade tered diciomresivesbie * ited orconfictig eee tomsinge andaized al onowandoried = uaty ot evencetoreconmenztonnot proves. While the patients stilinthe emergency department, and thatiso tonic cystalleid formulations are preferred (Table 3). Specialy lactated Ringer solutions recommended by most guidelines be- cause of an actacation between anapparentantinfarrmtory of fect and decreased ods of developing SIRS a 24 hourscompared with normal saline. The evidence favoring one crystalloid formula tion over anotherislow to moderate qualiy. The American College of Gastoenterolog’s(ACG)Acaite Pancreat Task Force on Qual ity guideline cteda meta-analysis reporting decreased odds ofde- veloping SIRS with actated Ringer solution compared with normal saline when used othe initia resuscitaonin acute pancreattis(OR, 0,38 [95% Cl 015-0.98).”*" This meta analyss was based on 3 CTs of whichonly I demonstrateda significant effect favornglac tated Ringer solution ** Most authortiesrecommend tratingintravenous fuidadmin: Istation to speatic measurable targets of perfusion® For ex ample.thelnterntionalAsseitionof Pancrexokgy nercan Pan cresticAssocistion (AP/APA) recommends acrystalloidinfesion of S5tel0mL/kglhuntilormere resuscitation galsaremet (eg heart ‘ate 20 beats por minute;mean starial presture, 65.85 mmHg Urine output “0.5 to ml; hemstocit, 3584496). Theriksof uid overload éuoto 2egroccve resuscitation i pationts with posit: Ingkdney disease or heat fallre mistalwaysbeconsidered. These sks can manifestas pulmonary eden, excessive hamodition ead ingto hypoxi, and intra abdominal hypertesion:®? Nutition The provsionof nutition isan important eatureof thecareofpa- tits withacute pancreatitis (Moderately severeand severe acute Pancreatitis ect anintense systemic inflammatory response re- ‘sulinginacatabolic state incessing caloric and nutritional require: ments. (2) Reduced intestival vascular perfusion in acute pancre ats may resultin gut mucosal damage, Subsequently intestinal permesbilty increases, whichmayenablethe ranslocationof bac teria fromthe bowel lumen tothe partacirculation and mesen- teric lymphatics. This couldresutin oganfalure, sepsis, and sec “ondaryinfection of pancreatic and peripancreatic necrosis." Early nuttin particularly enterinutitien, mitigates theseetfectsbysev- ‘eralmechanisms: replenishing cari sses, ncreasng splanchnic blood fowto preserve the integityof the bowel cos. and stinu- lating intestinal moti. Histoealy, there was reluctance to fed patients with acute pancreattc enterally because of concern thatthe inflamed pan ‘rose woul bostmulsted te cecrots, xaearbatingthe dace. Po. ‘ontralnutition was widelyused, However, this concernabouten- teralnutritonhasnotbeen validated, and evidence overwhemingly JAMA mary26,2021 Volume 35, Nanter © 2021 American Medical Association. All ights reserved.a supports enteral nutrition over parenteral nutrition A Cochrane metaanalyss of 8 studies involing 348 patients compared en- teralrutetion vstotl prentealrutrtion or the treatment of acute pancreatitis, finding that enteral auton wasassociated wth de- ‘reasesinmortaty ieitive risk {RR} 0.519596C1,0.28-091), mul: tiple organ flue (RR, 0.55 [95% Cl, 0.37-0.81), and sytemicin- fection (RR, 0.39 [95% Cl, 023-0.65)). On subgroup analysisfor severe acute pancreatitis, the decreased rsk for death inpatients rocevingentera nutriton waseven more profound (RR, 0.18 [95% cL0.06.058):° tis unnecessary to wait unt the pains resolved beforere suming alt inpatients who have acute pancreatis, The mast recent guidelines fromthe Amercan GastroenterlogislAssoda tion (AGA) Acute Pancreas TeskFore on Quality” and qual: ityincicator expert pane® recommend initiating erterl feeding Within 24 t072 hours abe 3). One meta analyss of RCTs with 651 patients demonstrated that inisting enteral feecingwithin24 hours of admission compared with delayed enteral feeding (24 hous) or parenteral auton was associated with adecrease inmutiple erga falure (OR, 0.4[95% CI, 0.2079}; = 008)4° In genera. patients tobating orl nutrition shouldbe placed on 2 low fat soft or slid dit* fpatiants ar unable to tolerate an eal lt within 72 hours, thay should be started on nacoenteal nut tion (a, nasogasteie or nasojuna).*®? Patents who canrot tl erate ontoral feeding éveto panlysc aus, obstucion or other causes should be started en garenteralnutition within 72 hour. Many patints are msinouriched pir tothe episode of acate pancreatitis. The consensus guideline from th Eurepesn Society for Clinical Nutition and Metabolism recommend performing 2 rutetion cereon fox al pstionte with mild to mederately severe acute pancreas using took sch a6 the Mahutition Screening Tool and Nutrition Risk Scrooning insteumont (NRS.2002)(:/) esponinfoldscumonts/Srsoring pa) Allpstiontewithsovore acito pancreatitis are considered 2k fr nutritional defiioncos °° Pationts with evidence of malabcception (saatorthes) require ‘exaluation fer exoctine pancreatic incficiency (og, fecal elastase And fecal ft ascayscr dec pancreatiuncton tt), Seminlomental formations, containpreciested proteins, cabohycates, tt) andl: pancraticerzyre supplomertation shouldbe consideredfor ‘thecopationts°°Tharealackof compelingovidercoto support ihe routine use of semielemertal tition o: enteral formas eriched with protiotiserimmuncnutition Risk Reduction and Follow-up Care Cholecystectomy Gallstones ae aleading cause of acute pancreatitis. When chale- cystectomy not performedat theindex admission for gallstone acute pancreattis. 8% of patients ae at risk fr recurrence of acute pancreatitis within a median of 40 days after ischare. The risk increases to 22% at 5 yeas f cholecystectomy snot performed *? Early cholecystectomy (within 4 to 48 hours of hospital admission) is safe and shortens hospital duration in patients witha predicted mid course of acute pancreatitis.” Same admission cholecystectomy may not be feasible for various reasons: patent preference, patents not mecicaly optimized for surgery, anda lack of hosital resources. Ontimaly, these patients should undergo cholecystectomy within 2 to 4 weeks after dis- charge, if deemed medically fit, to minimize the risk of recurrent {JAMA e726 2021 ohare 25 Nabe a acute pancreatitis related to gallsones. Patients with maderatey severe or severe acute pancreatitis shouldbe evaluated for pet pancreatic id olletions prior to cholecystectomy by performing ‘ contrastenhancedCTor MRlexaminaton, For patients whe have Peripancreaticcallecions er severe acute pancreatitis ealy cole cystectomy should not be performed because ofthe sk of super infection ofthe perpancreat: fluid cofectons and limitation of \suallation fom a bulgingrevopertoneum. The eperation should be delsyed until the fu collections resalve or after waiting for 6 weeks after the epizade of acute pancreatitis so that cholecystec: tomy can be combined with an internal drainage procedure (eg. cstgpstostomy) F necessary** ERCP with sphincterctomy sheuld be considered during the index admission to minimize recurent parcrestieduct cbse ucion frem anther migrating gill stone in patients who require adelayed cholecystectomy or in patients who are high surgical sk but this intervention mey not redhce the rate of subsequent blisy colic or choleystitiz” [cohol Cessation Statesies ‘leah related cute pancreatitis ¢ an indopendantpreditorof do veloping recurrent acstepancreatits(hazardatio,272 (95%, 191 3.83]: 8.5:month median time torecurrence) and chronic pancre: ati (ha2ardrato, 916 [95% 27130.90} 4-monthmediantime todeniepanereatie)? The AGA recommends perfermingsbiaf aleohalinterventionduringtheindexadmisionforaleahel-related acute pancreatitis, and addtional educatioalsassionsiné-month interval for 2 years afterdischarge Patients are counseled re garding 3 aspects ofthealeaho- pancreas relationship: thetoxicef- fects ofakohoon the pancreas, bahavioralchangee/atering dink inghabit, and focus on socioeeanemic ices Other terventions Obecopationts and thors wth hypertigycardamiachouldbe coun foled garding weight reduction, dietary modifistions, andl: holaveidince, Pharmacologic therapies include fates, state, niacin, and omega 3faty acids. Fibrates (eg fonofirste)have the srontostefficacyin lowering tigycordolovels andmay bo usedin ‘combination withthe othorlstad madiations for refractory cases Ponts fourdtohavohyperalcemiaduinganeptode facto pancreatitis should be evaluated for primary yperparathyradism 1. lesscomrronly. malignancy and thyrotoxicosis. Sequele The long-term effecs of acute pancreatitis are considerable. even in those with mid and first-time episodes Patiets are at riskto develop recurrent episodes of acute pancreatitis. progress 10 chronic pancreatitis. ane develop endocrine and exocrine irsufi- ciency The greatest riskfactors for developing recurrent acute pan creatits ae alcoholic acute pancreatitis bilary acute pancratis. without interval cholecystectomy. ar tabacco smoking. Rist fac: tors for progressing to chrenicpancreatisincluderecurent acute Dancreatts, tobacco smoking. pancreatic necrosis, and alcoholic acute pancreatitis" Pancreatic eccrine insuffcieny wil develop in up to 35% of all patients. The most important risks fcters include necrotizing acute pancreatitis and lcchol etiology. Patients with der ‘hes, steatonthea, ard/cr postive pancreatic exocrine insufficiency assays, suchas fecal elasase-|, fecal fat, or diect pancreatic G20 ienericnmtNedicdl eeociticn: Alirgprninemaronl.Acute Pancreatitis: A Review function tests, may benefitfrom pancreatic enzyme supplement ‘Hon. Fancrestogenic dabetes malts (type 3c aabetes) is the impairment n pancreatic endocrine function related to siuctural pancreatic damage dueto pancreatts. Type 3cchabetes closely ‘elated tochronic pancreas, but itmay aso develop in patenis who experienced an episode of severe necrotizing acute parcreatis:* tients with peripancreatic fad collections shouldbe fo- lomedregulaly and assessed for stable, improved, or worsening symptoms such a pin, feeding intolerance. and fevers. Insurmary, acute parcrenti’s isa complex and dynamic dis- case process with avaiable clinical course. Prompt recegnition, liognesis, nd ination of treatment with ery fd resurcitaton an early utiten ace important for good outcomes, Scorn tos areusefuladjancts for peedieting severity and morality. Inpatica lar, the BISAP score i easy to calculate and can be performed Wwithin24 hours. However, these tool chould not substtute cial Judgment Patients noed tobe evalustedfequently, and manage smentacjstd based on clinical findings and tend, Tero iscon- -oneus for ealy and aggressive volume resuscitation, but the rate, duration, and value are nat well-defined. The trend in markors Aaboratory studies. vita are important to follow Enter Feeding {is acttca aspect of managing al severities of acute pancreats. f possible. cholecystectomy should be performed inpatients with ‘mild alsione aute pancreattis during the index admission orf Considered unsafe during the admission. witin2 to 4 weeks after dlschargeto reduce risk ofrecurtence ofacite pancreatitis. npa- tient and outaatent alcohol rodfication/cessation strategies are likely elptl fused both nthe hospital and outpatient settings, ‘Aceopted fr Publation:Sapember 2, 2020, ‘isc tala tain the ty 8 ae ‘esgonsbityf:the ney ofthe dtaanthe Seewaryoftecataanajes. ConeptonddesneAtars ‘eqiston ana orrtretaton ft A autos. Drain of noscript: Alauhos. ict evson oft must for mre Intact conte ater. Stott oa: Neros Reber. ‘dminsrote ei or mater port I Supine i Confit of terest Oiadostres None spared. Submision We ecoragesutonstosibnit apr onstertonasaReveu Passe ‘ora EdordLngstn, HO at Eonar, Inirgstnamanetvorog or ary Mcrae McDermott MO at nGO8rertweer ede 2ons sone REFERENCES 1, Stes 20, M90, YUH. eta Natonwide luerdsia sate ndtv pancetta [tered csarenand nore ets 20181552)468-4781. 2. CargSK Sonepals.compbel Reta inne, amis ts, ad predicts, 2d cone burden facut omens Wt Ga e48, scatepoeresiti in Gastro 200.590) 2 Gendt Kravis Sha Tenparaterdsininedence and etcomesof sxuteporcrestsinfosptland atin inthe 4 Gap Hat AG. iter hae ace Feseymass' Tends andoutonesot Fspisxtons rate toacie incre epdenoogytiom2001 2018 nthe Unites ‘Siar Ponwor OMA) 55 5 Foxmar CE Nags, Mean. Aute ances. Eg Med 208 375(20) 1972981 6 rsh SG Kano AK Hat Ph, Hinton (Grell OL. Te chargngepemology face nce ospeatztons, anceas 20754643): 7 LaischPs Ate Boks PA Acie creat. ont 20853869988) 35:96, 8 Rowall.Bengson. Sener. Heiman M ‘tation ofthe emlerent cascade typ Bol chem Hope Sete 9137223278, 9. Uchans.HonyoK Fuukava S MiayaraA, Sanote oo" etalon snmp Remon pancreas At fp at 988247 ‘Review Clinical Review & Edecation Limitations ‘Thisreviwhassomelintaors sta formal systematic review vas ‘not performed, Second, acomprehensiveevaliation of acute pan eatts management (efor necrtizng acute pancreas oca com picatlors, or other sequelae of acute pancreatitis) was Pot re lewed. Thi, though te Importance of ud resuscitation and ‘utstioninthelnl management ofacute pancreas widely 3c cepted, te evidence for specficinterventionss limited, of moder atetolow quay, and eported inconsistent findings. Fourth, meth odological dvessity and satistical heterogeneity were fequertly encountered. For example. the meta-analyses the Muidancinust tional management of acte poncrestts incorporated a combing tion of studies that used eter the RAC severity clasifeaton, anal ternativeor outdated everityscerng stem. Thishasimplicstins whencomperingmethadcof maragament andiheoffecten so:s0 severity Fifth, thoe ate several acute pancroaths management guidlines of varying quality. Faature of guidelines with the highest ‘quality ncde those eeorsedtyprefessonserganization (AP. AGA. ACG), inclicea summaryof recemenations ane provide evi- dence grading forthe various ecammerdatons Conclusions ‘Actepanceatiisisacamplexdiseasethatvaresinsevertyandcouse. Prompt dagnoss and tratficationofseveityinfuencesproperman- agement Scorngsjsters axe sefuladuncsbushouldnot supersede clnicaludgynent Flidmanagement,ntrtion andrikredcionstat- etiesareveryimportat aspects of care for acutepancreatis. 1. Neiger 8, Abrecht Lenh MM The ole lntacelua cakomsialnginoreratae rte activation ndtheonseofpacreiis ‘nsPao.2000:57(04350 1B. LiAZ UR Zang LIF. Okamsraingot [pore ecar alta thepetogenss ef ‘ares Word Gott 7034204) Teno st, 1B. Kosar shina VS Afghan Ea Inge eve andmotaly fost RCP parce coronas 205581043 tees. 1. 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Then preetonatmoraa sn awe pncratts Git 20085712698 73, 29, Singh Ws BU Belen. ta ‘Apoospective eahusiono tebe idexfor ‘Seertyn zuteponentsscoremasesing totaly ondienedte rrr seer n @seeo7 30. stingAD. Moran 8 Kay ME, gay ‘Cerin he predcavevavectCrecive proven [CRP nace paces 78 (Oxf. Sowsa00)874 880, 23 Tyas 0, Ul KarncamanoghiAD. On Apia, Acuoyof ey CT figs fr prescing dsexe ceuseingatenswathacre purereats pn deco 208.360) 1518, -2.SahsD Abbey And Kamar, Toe 5, lk Severity asesnentofatepaneais sig CT Sever inex and road TSeverty Index ovation eh cnet oxeomes and ‘eityalingss pe the Rose tots (lst Ison Rzolimo3ing 200.270) 152160, 133, Busted AObady Ramah Meta. Panesitsimagingsppo%e: Vor) Garo Patepst 2044 50)252.270, 4 Tea Te ved Alona cseatoneh ‘ave poncratts:tsimsorancear the adlogst “nd effec ontetmen ily, 202.252 Gye 35, WuaU Johannes RS, Sun, Comet, Dan PA. Ely dergenBoodoree tog 390. 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WL, Sanlann i Pk. Mndsor Petrov Mesa olgutbarier estncon inpavenswitacepnereats. 1S, 20H: ‘AlAnsary UA Enteal vrs parenteral tron or ate anceats, cone Diba Sst Rev dureAcoonssr 46. 00, we.Huang Penge Meta-aapisc txlyeeol nition rosedmithn2¢hows et ‘nisionon cnc tones ace fcr. FEN Porte Enea. 2018.42 Gimme 47. Meng6.UX.UYM.ZneUWC Zhu XL Te Iie eter mangement of dct crits amets ans vi Gasvootet bonngna2is-a 48, Blk van Banc vor Sanveert HC at Oe Paereaas stay Goon Ea verte ondenondnaoentr tube fedgin cute crete Wéng Mt 2018371217983 993, 49, Duta AK GoelA Kalan CoA Tana Nasogasricresis nso tate fevdngorsevere aut pacrenits avon Duta Sat fer. 20293 10582 50, avantakM.Ockongs 1 Bezmoree Me FSPeNpidere online martoninariteond drone pacrests Int 2020390):62 63, 5. Propt, ica Howser, Sma: D Enteral ion fematons baste paces. Getrane Dataset en 205(0) COIS. Acute Panceatitis: AReview {sana HC, esi Baer at ‘BinchPacrnt sty Coun Tg of olrystcty ter mil ry panceatt: ssi fm Sr, 2122558) 860 966, ‘3, FvargSS. Lah, HognP Galore sanceatts was choleystectomy. Su, 54, sbouan, Cun, aghoubian Ata aly olecystcny safe decrees hosptal stayin stents with nator perexts: ‘stantomzedpropeciestn. 59.2010 uosser. 55 oubins ED. de Vigo. Seem ER Ki Noaner Asocatinafeatvdelyed olrytecey or mid asoneparcretts ‘wen penepente oucames. is, 218153 ‘ptosrioss 55, forAE do Wego Sable Et ty laparoscopic hokeysectomyforradgalstone ances. hr 202.3. 7. MaeceK, Weis PesoraC. al. Galktone heagtectomy andominedal(Etone ANC TH, A S.208.2700)519521 58. Nealon WH, Beni J aber Joprptte ting chokeyecnyin patos ho rest wahmoderae osevere flstone essocated wate porretisth ‘ergnncreati fad calecons An Sis, 2008 6)74-79 1. Magwuscotir8A, Sanson ME, Kabtaks, Copmsonts Rsk tos to choncane reeunentpocreaitsattefeatockot ste ‘anceats. cand JGastoenerel 209-5457 sm 60, Woreback, eH Lipabinn Leo ‘Bevien Ray Sag herecerce face ‘Seat esocated porcetite en be refed Gostoenrobay 2009:0603.848 855, 61 ame AU 50 Hager. Ouch FanceatsSudy Group. Aiskotreurent ancestis and progression tocnicprereaits erafatepoode ofc pnceatts cin (Gosipenrt Hepatol 206345) 738 746. (2. Hoemaes RA. Halen NOL. Mags € a: Duth Pancras stay Groxp. Fanceate ‘ocine rsutloencylewng sete panceats Pomaeatoy. 2018183259262 (2. HuargW. de gis Gorie Baton Rel sal Berne parce nsficaney lone uteporeredits 0905 2018647) 385 (4, a. Zu Lea Ween Pando, UL ncn of eon betes eltan Seconda tact pancreas rn Py isto, (6, Sr, 201 resin ofthe eta asfcaon of aut pneeats, Po Whee Wes 200,290)8 2 66, Lovely nna, ate R tal Mi ‘lity ndvarbl unto eines fe aute fcr: asst review SCs Fo101057) wee 75. {@:MLET Rinse Macioed Atsaclaticn: Aid ts eanrved::Supplemental Online Content Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: a review. JAMA. doi: 10,1004 /jama.2020.20317 eBox. Commonly Asked Questions About Acute Pancreatitis This supplemental material has been provided by the authors to give readers additional information about their work. © 2020 American Medical Association. All rights reserved.