Cited by 2,327Pancreatitis Pathology and TreatmentGallbladder and Bile Duct DisordersSepsis Diagnosis and Treatment

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American College of Gastroenterology Guideline: Management of Acute Pancreatitis

Tenner, Scott, Baillie, John, DeWitt, John, Vege, Santhi Swaroop·2013·American Journal of Gastroenterology

DOI 10.1038/ajg.2013.218

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Abstract

This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.

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Influential
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Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis
Rompianesi, G., Hann, A., Komolafe, O., Pereira, S. P., Davidson, B. R., & Gurusamy, K. S. (2017) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012010.pub2 · Cited by 135
Extra-hepatic manifestations associated with hepatitis E virus infection: a comprehensive review of the literature
Bazerbachi, F., Haffar, S., Garg, S. K., & Lake, J. R. (2015) · Gastroenterology report · doi:10.1093/gastro/gov042 · Cited by 129
“All cases fulfilled the criteria of the American College of Gastroenterology for the diagnosis of AP [37].”
Method
Aktualisierte S3-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) zur Prävention, Diagnostik und Behandlung von Gallensteinen
Gutt, C. N., Jenssen, C., Barreiros, A. P., Götze, T. O., Stokes, C. S., Jansen, P. L., Neubrand, M., Lammert, F., der Konsensuskonferenz, F. D. T., (DGIM), D. G. F. I. M. E. V., et al. (2018) · Zeitschrift für Gastroenterologie · doi:10.1055/a-0644-2972 · Cited by 133
“[735] Tenner S, Baillie J, DeWitt J et al.”
Background
Clinical and Genetic Risk Factors for Acute Pancreatitis in Patients With Acute Lymphoblastic Leukemia
Liu, C., Yang, W., Devidas, M., Cheng, C., Pei, D., Smith, C. J., Carroll, W. L., Raetz, E. A., Bowman, W. P., Larsen, E. C., et al. (2016) · Journal of Clinical Oncology · doi:10.1200/jco.2015.64.5812 · Cited by 126
“There is no specific treatment of acute pancreatitis; only supportive care is given.(36) Thus, the genetic and nongenetic risk factors we discovered in this largest study to date may have importance for understanding the mechanisms and developing targeted interventions for patients with predisposition to pancreatitis.”
Background
The Anti-Inflammatory and Curative Exponent of Probiotics: A Comprehensive and Authentic Ingredient for the Sustained Functioning of Major Human Organs
Virk, M. S., Virk, M. A., He, Y., Tufail, T., Gul, M., Qayum, A., Rehman, A., Rashid, A., Ekumah, J., Han, X., et al. (2024) · Nutrients · doi:10.3390/nu16040546 · Cited by 144
Familial chylomicronemia syndrome: Bringing to life dietary recommendations throughout the life span
Williams, L., Rhodes, K. S., Karmally, W., Welstead, L. A., Alexander, L., & Sutton, L. (2018) · Journal of Clinical Lipidology · doi:10.1016/j.jacl.2018.04.010 · Cited by 125
“During attacks of acute pancreatitis, early aggressive IV hydration with 250 to 500 mL/h may prevent intravascular volume depletion and pancreatic necrosis.(50,51) Ideally, initiating IV hydration within the first 12 hours of acute pancreatitis onset may prevent further complications.”
Background
EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis
Párniczky, A., Abu‐El‐Haija, M. A., Husain, S. Z., Lowe, M. E., Oracz, G., Sahin‐Tóth, M., Szabó, F., Uç, A., Wilschanski, M. A., Witt, H., et al. (2018) · Pancreatology · doi:10.1016/j.pan.2018.01.001 · Cited by 131
“A small percentage of the cases with confirmed infected necrosis, whose clinical status is stable, can be treatedwith only antibiotics, without the need for drainage or necrosectomy [112,113].”
BackgroundInfluential
Pancreatic Cancer Following Acute Pancreatitis: A Population-based Matched Cohort Study
Sadr‐Azodi, O., Oskarsson, V., Discacciati, A., Videhult, P., Askling, J., & Ekbom, A. (2018) · The American Journal of Gastroenterology · doi:10.1038/s41395-018-0255-9 · Cited by 125
Acute Pancreatitis
Gardner, T. B. (2021) · Annals of Internal Medicine · doi:10.7326/aitc202102160 · Cited by 122
Low-grade inflammation in the association between mild-to-moderate hypertriglyceridemia and risk of acute pancreatitis: a study of more than 115000 individuals from the general population
Hansen, S. E. J., Madsen, C. M., Varbo, A., & Nordestgaard, B. G. (2019) · Clinical Chemistry · doi:10.1373/clinchem.2018.294926 · Cited by 121
Interventions for necrotising pancreatitis
Gurusamy, K. S., Belgaumkar, A. P., Haswell, A., Pereira, S. P., & Davidson, B. R. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011383.pub2 · Cited by 118
Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging
Zhao, K., Adam, S. Z., Keswani, R. N., Horowitz, J. M., & Miller, F. H. (2015) · American Journal of Roentgenology · doi:10.2214/ajr.14.14056 · Cited by 120
“Despite this, imaging for the detection of necrosis within the early phase is generally only indicated in deteriorating or critically ill patients and must be interpreted cautiously [7].”
BackgroundMethodInfluential
Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis
Vipperla, K., Somerville, C., Furlan, A., Koutroumpakis, E., Saul, M. I., Chennat, J. S., Rabinovitz, M., Whitcomb, D. C., Slivka, A., Papachristou, G. I., et al. (2016) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000000579 · Cited by 121
Acute Pancreatitis: Updates for Emergency Clinicians
Waller, A., Long, B., Koyfman, A., & Gottlieb, M. A. (2018) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2018.08.009 · Cited by 128
Azathioprine-induced Acute Pancreatitis in Patients with Inflammatory Bowel Diseases—A Prospective Study on Incidence and Severity
Teich, N., Mohl, W., Bokemeyer, B., Bündgens, B., Büning, J., Miehlke, S., Hüppe, D., Maaser, C., Klugmann, T., Kruis, W., et al. (2015) · Journal of Crohn s and Colitis · doi:10.1093/ecco-jcc/jjv188 · Cited by 115
Abdominal Compartment Syndrome and Intra‐abdominal Ischemia in Patients with Severe Acute Pancreatitis
Smit, M., Buddingh, K. T., Bosma, B., Nieuwenhuijs, V. B., Hofker, H. S., & Zijlstra, J. G. (2016) · World Journal of Surgery · doi:10.1007/s00268-015-3388-7 · Cited by 110
“Three commonly used guidelines by the British Society of Gastroenterology [20], the American College of Gastroenterology [21], and the American Gastroenterological Association [22] do not yet mention the need for routine IAP measurements.”
Method
Caffeine protects against experimental acute pancreatitis by inhibition of inositol 1,4,5-trisphosphate receptor-mediated Ca 2+ release
Huang, W., Cane, M. C., Mukherjee, R., Szatmary, P., Zhang, X., Elliott, V., Ouyang, Y., Chvanov, M., Latawiec, D., Wen, L., et al. (2015) · Gut · doi:10.1136/gutjnl-2015-309363 · Cited by 108
Hypertriglyceridaemia-associated acute pancreatitis: diagnosis and impact on severity
Zhang, R., Deng, L., Jin, T., Zhu, P., Shi, N., Jiang, K., Li, L., Yang, X., Guo, J., Yang, X., et al. (2019) · HPB · doi:10.1016/j.hpb.2019.01.015 · Cited by 107
Mechanisms and Management of Acute Pancreatitis
Garber, A., Vozzo, C. F., Arora, Z., & Chahal, P. (2018) · Gastroenterology Research and Practice · doi:10.1155/2018/6218798 · Cited by 109
“Further randomized trials utilizing prophylactic antibiotics have failed to show benefit [8].”
BackgroundInfluential
Systemic immune-inflammation index (SII) can be an early indicator for predicting the severity of acute pancreatitis: a retrospective study.
Liu, X., Guan, G., Cui, X., Liu, Y., Liu, Y., & Luo, F. (2021) · International Journal of General Medicine · doi:10.2147/ijgm.s343110 · Cited by 105
“29,33 In recent years, studies have explored the use of new types of severity and predictive scores such as NLR and PLR for predicting the severity of pancreatitis.”
Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study
Chen, Y., Yang, J. F., Friedland, S., Holmes, I., Law, R. J., Hosmer, A. E., Stevens, T., Franco, M. C., Jang, S. N., Pawa, R., et al. (2019) · Endoscopy International Open · doi:10.1055/a-0828-7630 · Cited by 105
Enteral nutrition in acute pancreatitis: A review of the current evidence
Oláh, A., & Romics, L. (2014) · World Journal of Gastroenterology · doi:10.3748/wjg.v20.i43.16123 · Cited by 107
Contemporary review of drug-induced pancreatitis: A different perspective
Hung, W. Y. (2014) · World Journal of Gastrointestinal Pathophysiology · doi:10.4291/wjgp.v5.i4.405 · Cited by 104
Timing of catheter drainage in infected necrotizing pancreatitis
for the Dutch Pancreatitis Study Group, van Grinsven, J., van Santvoort, H. C., Boermeester, M. A., Dejong, C. H. C., van Eijck, C. H. J., Fockens, P., & Besselink, M. G. (2016) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/nrgastro.2016.23 · Cited by 104
BISAP, RANSON, lactate and others biomarkers in prediction of severe acute pancreatitis in a European cohort
Valverde‐López, F., Matas-Cobos, A. M., Alegría-Motte, C., Jiménez‐Rosales, R., Úbeda‐Muñoz, M., & Redondo‐Cerezo, E. (2017) · Journal of Gastroenterology and Hepatology · doi:10.1111/jgh.13763 · Cited by 104
Enhanced Neutrophil Extracellular Trap Formation in Acute Pancreatitis Contributes to Disease Severity and Is Reduced by Chloroquine
Murthy, P., Singhi, A. D., Ross, M. A., Loughran, P., Paragomi, P., Papachristou, G. I., Whitcomb, D. C., Zureikat, A. H., Lotze, M. T., Zeh, H. J., et al. (2019) · Frontiers in Immunology · doi:10.3389/fimmu.2019.00028 · Cited by 105
“care, highlighting the critical need for novel therapies that target the underlying pathophysiology of the disease (1).”
Background
S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003
Beyer, G., Hoffmeister, A., Michl, P., Gress, T. M., Huber, W., Algül, H., Neeße, A., Meining, A. G., Seufferlein, T. T. W., Rosendahl, J., et al. (2022) · Zeitschrift für Gastroenterologie · doi:10.1055/a-1735-3864 · Cited by 108
Acute pancreatitis: an update on the revised Atlanta classification
Colvin, S. D., Smith, E. N., Morgan, D. E., & Porter, K. K. (2019) · Abdominal Radiology · doi:10.1007/s00261-019-02214-w · Cited by 103
Necrotizing Pancreatitis: Current Management and Therapies
Boumitri, C., Brown, E., & Kahaleh, M. (2017) · Clinical Endoscopy · doi:10.5946/ce.2016.152 · Cited by 98
Diabetes following acute pancreatitis
Hart, P. A., Bradley, D. P., Conwell, D. L., Dungan, K. M., Krishna, S. G., Wyne, K. L., Bellin, M. D., Yadav, D. K., Andersen, D. K., Serrano, J., et al. (2021) · The Lancet. Gastroenterology & hepatology · doi:10.1016/s2468-1253(21)00019-4 · Cited by 107
Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial
Bang, J. Y., Lakhtakia, S., Thakkar, S. J., Buxbaum, J. L., Waxman, I., Sutton, B. S., Memon, S. F. F., Singh, S., Basha, J., Singh, A., et al. (2023) · The Lancet. Gastroenterology & hepatology · doi:10.1016/s2468-1253(23)00331-x · Cited by 102
Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial
Mok, S. R. S., Ho, H. C., Shah, P., Patel, M., Gaughan, J. P., & Elfant, A. (2016) · Gastrointestinal Endoscopy · doi:10.1016/j.gie.2016.10.033 · Cited by 95
The role of endoscopy in benign pancreatic disease
Chandrasekhara, V., Chathadi, K. V., Acosta, R. D., Decker, G. A., Early, D. S., Eloubeidi, M. A., Evans, J. A., Faulx, A. L., Fanelli, R. D., Fisher, D. A., et al. (2015) · Gastrointestinal Endoscopy · doi:10.1016/j.gie.2015.04.022 · Cited by 95
Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study
van Grinsven, J., van Brunschot, S., Bakker, O. J., Bollen, T. L., Boermeester, M. A., Bruno, M. J., Dejong, C. H. C., Dijkgraaf, M. G. W., van Eijck, C. H. J., Fockens, P., et al. (2015) · HPB · doi:10.1016/j.hpb.2015.07.003 · Cited by 100
Acute Pancreatitis—Progress and Challenges
Afghani, E., Pandol, S. J., Shimosegawa, T., Sutton, R., Wu, B. U., Vege, S. S., Gorelick, F. S., Hirota, M., Windsor, J. A., Lo, S. K., et al. (2015) · Pancreas · doi:10.1097/mpa.0000000000000500 · Cited by 95
Clinical profiles and outcomes in idiopathic duct-centric chronic pancreatitis (type 2 autoimmune pancreatitis): the Mayo Clinic experience
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Disconnected pancreatic duct syndrome: Updated review on clinical implications and management
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Fluid resuscitation in acute pancreatitis
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Management and outcomes of acute pancreatitis patients over the last decade: A US tertiary-center experience
Koutroumpakis, E., Slivka, A., Furlan, A., Dasyam, A. K., Dudekula, A. B., Greer, J. B., Whitcomb, D. C., Yadav, D. K., & Papachristou, G. I. (2016) · Pancreatology · doi:10.1016/j.pan.2016.10.011 · Cited by 92
“The diagnosis of AP was defined as the presence of at least two of the three following criteria: 1) Epigastric abdominal pain that is typical of AP, 2) Serum amylase or lipase elevated to greater than three times the upper limit of normal, and/or 3) CT scan (or less commonly magnetic resonance imaging [MRI]) findings…”
Background
Ringer's lactate versus normal saline in acute pancreatitis: A systematic review and meta‐analysis
Iqbal, U., Anwar, H., & Scribani, M. (2018) · Journal of Digestive Diseases · doi:10.1111/1751-2980.12606 · Cited by 95
A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management
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“, within 24 hours) for SAP associated with acute cholangitis, as a delay is associated with an increased risk of mortality (16,17,147-149).”
Background
Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards
Jabłońska, B., & Mrowiec, S. (2021) · Nutrients · doi:10.3390/nu13051498 · Cited by 94
“EEN is also associated with a shorter duration of hospitalization and lower hospital costs [46,47].”
Background
Imaging in pancreatic disease
Dimastromatteo, J., Brentnall, T. A., & Kelly, K. A. (2016) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/nrgastro.2016.144 · Cited by 92

Authors: Tenner, S., Baillie, J., DeWitt, J., & Vege, S. S.
Affiliations: SUNY Downstate Health Sciences University (US)
Carteret General Hospital (US)
Mayo Clinic (US)
Corresponding author: Vege, Santhi Swaroop
ORCID: Baillie, John
DeWitt, John
Vege, Santhi Swaroop
Venue: American Journal of Gastroenterology
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2013-09
Volume: 108
Issue: 9
Pages: 1400-1415
ISSN: 0002-9270 (ISSN-L)
DOI: 10.1038/ajg.2013.218
OpenAlex: W1972516036
Semantic Scholar: 47448440997e168032405b8c54dc2587912c980b
Cited by: 2,327
References: 164
Citations by year: 2026: 110 · 2025: 117 · 2024: 179 · 2023: 256 · 2022: 250 · 2021: 244 · 2020: 220 · 2019: 191 · 2018: 192 · 2017: 175 · 2016: 144 · 2015: 159 · 2014: 82 · 2013: 3
FWCI: 125.98
Type: journal article
Language: en
Update notices: erratum (2014-02-05)
Open access: closed
Licence: www.springer.com/tdm (unspecified)
Locations: The American Journal of Gastroenterology (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Surgery › Pancreatitis Pathology and Treatment
Health Sciences › Medicine › Gastroenterology › Gallbladder and Bile Duct Disorders
Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Sepsis Diagnosis and Treatment
Keywords: acute pancreatitis, contrast-enhanced CT, hemodynamic resuscitation, systemic inflammatory response syndrome, intensive care unit admission, intravenous hydration, acute cholangitis, endoscopic retrograde cholangiopancreatography, post-ERCP pancreatitis, pancreatic stent, antibiotic prophylaxis, infected pancreatic necrosis, sterile pancreatic necrosis, enteral nutrition, parenteral nutrition, pancreatic pseudocyst
MeSH terms: Acute Disease, Cholangiopancreatography, Endoscopic Retrograde, Drainage, Gastroenterology, Humans, Pancreas, Pancreatic Ducts, Pancreatitis, Prognosis

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American College of Gastroenterology Guideline: Management of Acute Pancreatitis

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