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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BackgroundInfluential
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Method
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Advances in Management of Acute Pancreatitis
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BackgroundMethodInfluential
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“Pakistan journal of medical sciences, 35(4), 1008-1012.”
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“Furthermore, we compared the JPN Guidelines 2015 with the other two guidelines, IAP/APA Evidence-based Guidelines 2013 [17] and ACG Guideline 2013 [18], both of which were previously ranked as the four”
BackgroundResult
EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V – EUS-Guided Therapeutic Interventions (short version)
Fusaroli, P., Jenssen, C., Hocke, M., Burmester, E., Buscarini, E., Havre, R. F., Ignee, A., Săftoiu, A., Vilmann, P., Nolsøe, C., et al. (2016) · Ultraschall in der Medizin - European Journal of Ultrasound · doi:10.1055/s-0035-1553742 · Cited by 62
Chinese Herbal Medicines Attenuate Acute Pancreatitis: Pharmacological Activities and Mechanisms
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“…during the 1963 Marseille meeting, the management guidelines of AP have been enacted one after another; so far, a preliminary consensus regarding the treatment for AP has been established (Tenner et al., 2013; Working Group IAP/APA Acute Pancreatitis Guidelines, 2013; Yokoe et al., 2015).”
Background
Aggressive Hydration With Lactated Ringer Solution in Prevention of Postendoscopic Retrograde Cholangiopancreatography Pancreatitis
Zhang, Z.-F., Duan, Z., Wang, L.-X., Zhao, G., & Deng, W. (2017) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000000781 · Cited by 63
“12 Six domains were used to assess the risk of bias in this meta-analysis:(1) random sequence generation (selection bias), (2) allocation concealment (selection bias), (3) blinding of participants and personnel (performance bias), (4) blinding of outcome assessment (detection bias), (5) incomplete outcome data (attrit…”
Method
Acute pancreatitis: update on management
Nesvaderani, M., Eslick, G. D., & Cox, M. R. (2015) · The Medical Journal of Australia · doi:10.5694/mja14.01333 · Cited by 62
Improved Neurological Outcome With Mild Hypothermia in Surviving Patients With Massive Cerebral Hemispheric Infarction
Su, Y., Fan, L., Zhang, Y., Zhang, Y., Ye, H., Gao, D., Chen, W., & Liu, G. (2015) · Stroke · doi:10.1161/strokeaha.115.009789 · Cited by 62
Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial
Štimac, D., Poropat, G., Hauser, G., Licul, V., Franjić, N., Zujić, P. V., & Milić, S. (2016) · Pancreatology · doi:10.1016/j.pan.2016.04.003 · Cited by 66
“Oral intake can be started as soon as the patient is able to tolerate it [12].”
Background
Inhibition of miR-155 reduces impaired autophagy and improves prognosis in an experimental pancreatitis mouse model
Wan, J., Yang, X., Ren, Y., Li, X., Zhu, Y., Haddock, A. N., Ji, B., Xia, L., & Lü, N. (2019) · Cell Death and Disease · doi:10.1038/s41419-019-1545-x · Cited by 61
Serum D-dimer levels at admission for prediction of outcomes in acute pancreatitis
Wan, J., Yang, X., He, W., Zhu, Y., Zhu, Y., Zeng, H., Liu, P., Xia, L., & Lü, N. (2019) · BMC Gastroenterology · doi:10.1186/s12876-019-0989-x · Cited by 61
Pancreatic duct guidewire placement for biliary cannulation for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis
Tse, F., Yuan, Y., Bukhari, M. A., Leontiadis, G. I., Moayyedi, P., & Barkun, A. N. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd010571.pub2 · Cited by 60
Nasogastric Nutrition versus Nasojejunal Nutrition in Patients with Severe Acute Pancreatitis: A Meta-Analysis of Randomized Controlled Trials
Zhu, Y., Yin, H., Zhang, R., Ye, X., & Wei, J. (2016) · Gastroenterology Research and Practice · doi:10.1155/2016/6430632 · Cited by 60
“According to the guidelines for acute pancreatitis from the American College of Gastroenterology, in mild acute pancreatitis, oral intake is usually restored quickly, and no nutritional intervention is needed [5].”
BackgroundInfluential
Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis
Chen, H., Ji, L., Li, L., Wang, G., Bai, X., Cheng, C., & Sun, B. (2017) · Medicine · doi:10.1097/md.0000000000007487 · Cited by 62
Immediate Oral Refeeding in Patients With Mild and Moderate Acute Pancreatitis
Ramírez‐Maldonado, E., Gordo, S. L., Pueyo, E., Sánchez, A., Mayol, S., González, S., Elvira, J., Memba, R., Fondevila, C., & Jorba, R. (2020) · Annals of Surgery · doi:10.1097/sla.0000000000004596 · Cited by 65
Early Changes in Blood Urea Nitrogen (BUN) Can Predict Mortality in Acute Pancreatitis: Comparative Study between BISAP Score, APACHE‐II, and Other Laboratory Markers—A Prospective Observational Study
Pando, E., Alberti, P., Mata, R., Gómez-Jurado, M. J., Vidal, L., de Tudela, A. C., Dopazo, C., Blanco, L., Gómez‐Gavara, C., Caralt, M., et al. (2021) · Canadian Journal of Gastroenterology and Hepatology · doi:10.1155/2021/6643595 · Cited by 60
“It was thought that hyperfluid hydration policy in AP patients could be a better strategy in the past [33].”
Mortality in acute pancreatitis with persistent organ failure is determined by the number, type, and sequence of organ systems affected
Machicado, J. D., Gougol, A., Tan, X., Gao, X., Paragomi, P., Pothoulakis, I., Talukdar, R., Kochhar, R. K., Goenka, M. K., Gulla, A., et al. (2021) · United European Gastroenterology Journal · doi:10.1002/ueg2.12057 · Cited by 62
“Diagnosis of AP was based on presence of at least two of the three diagnostic criteria according to the American College of Gastroenterology (Table S1).(23) Subjects with chronic pancreatitis or pancreatic cancer were excluded.”
Method
Systematic review and meta-analysis of fluid therapy protocols in acute pancreatitis: type, rate and route
Martino, M. D., van Laarhoven, S., Ielpo, B., Ramia, J. M., Vázquez, A. M., Martínez‐Pérez, A., Pavel, M.-C., Beltrán-Miranda, P., Orti-Rodriguez, R. J., la Serna, S. C. D., et al. (2021) · HPB · doi:10.1016/j.hpb.2021.06.426 · Cited by 61
Acute Lipotoxicity Regulates Severity of Biliary Acute Pancreatitis without Affecting Its Initiation
Durgampudi, C., Noel, P., Patel, K. S., Cline, R. A., Trivedi, R. N., DeLany, J. P., Yadav, D. K., Papachristou, G. I., Lee, K., Acharya, C., et al. (2014) · American Journal Of Pathology · doi:10.1016/j.ajpath.2014.02.015 · Cited by 59
Abnormal laboratory results: Blood tests for acute pancreatitis
Basnayake, C., & Ratnam, D. T. (2015) · Australian Prescriber · doi:10.18773/austprescr.2015.043 · Cited by 61
Visceral Adiposity Predicts Severity of Acute Pancreatitis
Natu, A., Stevens, T., Kang, L., Yasinow, S., Mansoor, E., López, R., Glessing, B. R., Remer, E. M., Richards, T. J., Gupta, A. B., et al. (2017) · Pancreas · doi:10.1097/mpa.0000000000000845 · Cited by 56
“The diagnosis of AP was confirmed using the American College of Gastroenterology Practice Guidelines, which requires the presence of at least 2 of the following 3 criteria: (1) characteristic pancreatic abdominal pain, (2) elevation in serum lipase or amylase to 3 times greater than the upper limit of normal, and (3)…”
Method
Drug-Induced Acute Pancreatitis: An Evidence-Based Classification (Revised)
Saini, J., Marino, D., Badalov, N. L., Vugelman, M., & Tenner, S. M. (2023) · Clinical and Translational Gastroenterology · doi:10.14309/ctg.0000000000000621 · Cited by 60
Artificial neural network predicts the need for therapeutic ERCP in patients with suspected choledocholithiasis
Jovanović, P., Salkic, N. N., & Zerem, E. (2014) · Gastrointestinal Endoscopy · doi:10.1016/j.gie.2014.01.023 · Cited by 62
High-Density Lipoprotein Cholesterol, Blood Urea Nitrogen, and Serum Creatinine Can Predict Severe Acute Pancreatitis
Hong, W., Lin, S., Zippi, M., Geng, W., Stock, S., Zimmer, V., Xu, C., & Zhou, M. (2017) · BioMed Research International · doi:10.1155/2017/1648385 · Cited by 57
Gallstones: Watch and wait, or intervene?
Ibrahim, M., Sarvepalli, S., Morris‐Stiff, G. J., Rizk, M. K., Bhatt, A., Walsh, R. M., Hayat, U., Garber, A., Vargo, J. J., & Burke, C. A. (2018) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.85a.17035 · Cited by 58
“25 The diagnosis of acute pancreatitis requires at least 2 of the following: 26,27 • Abdominal pain (typically epigastric, often radiating to the back) • Amylase or lipase levels at least 3 times above the normal limit • Imaging fi ndings that suggest acute pancreatitis.”
Acute Pancreatitis Review
Huang, Y., & Badurdeen, D. (2023) · The Turkish Journal of Gastroenterology · doi:10.5152/tjg.2023.23175 · Cited by 63
Incidence and Predictors of Readmissions in Acute Pancreatitis
Garg, S. K., Campbell, J. P., Anugwom, C. M., Wadhwa, V., Singh, R., Gupta, N., & Sanaka, M. R. (2017) · Pancreas · doi:10.1097/mpa.0000000000000952 · Cited by 57
“Taken together, these findings are consistent with previous studies that found a reduction in readmissions with cholecystectomy during index admission for AP,(30) and multiple guidelines recommend performing cholecystectomy during index admission in cases of suspected biliary pancreatitis.(31,32) When looking specific…”
Result
Nutritional Aspects of Acute Pancreatitis
Roberts, K. M., Nahikian-Nelms, M. L., Ukleja, A., & Lara, L. F. (2017) · Gastroenterology Clinics of North America · doi:10.1016/j.gtc.2017.10.002 · Cited by 61
Gastrointestinal microecology: a crucial and potential target in acute pancreatitis
Cen, M.-E., Wang, F., Su, Y., Zhang, W.-J., Sun, B., & Wang, G. (2018) · APOPTOSIS · doi:10.1007/s10495-018-1464-9 · Cited by 57
“The impact of GI microflora dysbiosis on the progress of AP The intestine is the central organ of surgical stress as well as the target organ of MODS and the initiative organ during the course of AP.”
BackgroundInfluential
Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management
Vivian, E., Cler, L. R., Conwell, D. L., Coté, G. A., DICKERMAN, R. M., Freeman, M. L., Gardner, T. B., Hawes, R. H., Kedia, P. S., Krishnamoorthi, R., et al. (2019) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000000264 · Cited by 60
Ringer’s Lactate Prevents Early Organ Failure by Providing Extracellular Calcium
Khatua, B., Yaron, J. R., El-Kurdi, B., Kostenko, S., Papachristou, G. I., & Singh, V. P. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9010263 · Cited by 56
“The volume of these (55 mL/kg/24 h) is in the range used for IV fluid resuscitation in humans during severe pancreatitis [38,39].”
Background
Nutrition in acute pancreatitis: a critical review
Lodewijkx, P. J., Besselink, M. G., Witteman, B. J., Schepers, N. J., Gooszen, H. G., van Santvoort, H. C., Bakker, O. J., & Pancreatitis, O. B. O. T. D. (2016) · Expert Review of Gastroenterology & Hepatology · doi:10.1586/17474124.2016.1141048 · Cited by 67
Damage Control Surgery for Non‐traumatic Abdominal Emergencies
Girard, É., Abba, J., Boussat, B., Trilling, B., Mancini, A., Bouzat, P., Létoublon, C., Chirica, M., & Arvieux, C. C. (2017) · World Journal of Surgery · doi:10.1007/s00268-017-4262-6 · Cited by 56
“Indications of surgery for acute pancreatitis have evolved recently [35] and a high number of patients (42%) in the present study underwent DCS for ACS-related complications; prompt decompression had important effects despite need for prolonged OA management.”
Background
Pancreatic Disorders
Uç, A., & Fishman, D. S. (2017) · Pediatric Clinics of North America · doi:10.1016/j.pcl.2017.01.010 · Cited by 55
Management of Acute and Chronic Pancreatitis
Stecca, T., Nistri, C., Pauletti, B., Giacomo, A. D., Colaut, F., Ruperto, M., Caratozzolo, E., Bonariol, L., & Massani, M. (2023) · IntechOpen eBooks · doi:10.5772/intechopen.109115 · Cited by 55
Analgesia in the Initial Management of Acute Pancreatitis: A Systematic Review and Meta‐Analysis of Randomised Controlled Trials
Thavanesan, N., White, S., Lee, S., Ratnayake, B., Oppong, K. W., Nayar, M. K., Sharp, L., Drewes, A. M., Capurso, G., de‐Madaria, E., et al. (2022) · World Journal of Surgery · doi:10.1007/s00268-021-06420-w · Cited by 55
Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis
Tarján, D., Szalai, E. Á., Lipp, M., Verbói, M., Kói, T., Erőss, B. M., Teutsch, B., Faluhelyi, N., Hegyi, P., & Mikó, A. (2024) · International Journal of Molecular Sciences · doi:10.3390/ijms25021273 · Cited by 63
“Therefore, it is recommended to provide aggressive hydration to all patients, especially during the first 12–24 hours (h), unless restricted by cardiovascular or renal comorbidities [2–4].”
Background
The Long-term Prospective Follow-up of Pancreatic Function After the First Episode of Acute Alcoholic Pancreatitis
Nikkola, J., Laukkarinen, J., Lahtela, J. T., Seppänen, H. E., Järvinen, S., NORDBACK, I. H., & Sand, J. A. (2016) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000000564 · Cited by 55
Evaluation of the prognostic value of neutrophil to lymphocyte ratio in patients with hypertriglyceridemia-induced acute pancreatitis
Wang, Y., Fuentes, H. E., Attar, B. M., Jaiswal, P., & Demetria, M. V. (2017) · Pancreatology · doi:10.1016/j.pan.2017.10.001 · Cited by 56
Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled,open-label study
Tozlu, M., Kayar, Y., İnce, A. T., Baysal, B., & Şentürk, H. (2018) · The Turkish Journal of Gastroenterology · doi:10.5152/tjg.2018.18583 · Cited by 55
Development and validation of a novel clinical scoring system for short-term prediction of death in dogs with acute pancreatitis
Fabrès, V., Dossin, O., Reif, C., Campos, M. A. L., Freiche, V., Maurey, C., Pilot‐Storck, F., Desquilbet, L., & Benchekroun, G. (2019) · Journal of Veterinary Internal Medicine · doi:10.1111/jvim.15421 · Cited by 55
“In human medicine, early identification of severe AP is considered mandatory to initiate appropriate treatment as early as possible to decrease death rate.(5,14) Several scoring systems including Ranson, Glasgow, APACHE II (Acute Physiology and Chronic Health Evaluation II), BISAP (Bedside Index of Severity in Acute P…”
BackgroundMethod
Factors Associated With Opioid Use in Patients Hospitalized for Acute Pancreatitis
Wu, B. U., Butler, R. K., & Chen, W. (2019) · JAMA Network Open · doi:10.1001/jamanetworkopen.2019.1827 · Cited by 55
“5) 10 (0-30) [4-16] Personality disorders No 4299 (99.”
BackgroundInfluential
Development and validation of a risk prediction score for severe acute pancreatitis
Hong, W., Lillemoe, K. D., Pan, S., Zimmer, V., Kontopantelis, E., Stock, S., Zippi, M., Wang, C., & Zhou, M. (2019) · Journal of Translational Medicine · doi:10.1186/s12967-019-1903-6 · Cited by 56
The clinical value of adipokines in predicting the severity and outcome of acute pancreatitis
Karpavičius, A., Dambrauskas, Ž., Gradauskas, A., Samuilis, A., Žvinienė, K., Kupčinskas, J., Brimas, G., Mečkovski, A., Šileikis, A., & Strupas, K. (2016) · BMC Gastroenterology · doi:10.1186/s12876-016-0514-4 · Cited by 54
Thoracic epidural analgesia: a new approach for the treatment of acute pancreatitis?
Windisch, O. L., Heidegger, C., Giraud, R., Morel, P., & Bühler, L. H. (2016) · Critical Care · doi:10.1186/s13054-016-1292-7 · Cited by 60
Continuous intravenous infusion of insulin and heparin vs plasma exchange in hypertriglyceridemia‐induced acute pancreatitis
Jin, M., Peng, J., Zhu, H., Zhang, H. M., Lü, B., Li, Y., Qian, J., Yu, X., & Yang, H. B. (2018) · Journal of Digestive Diseases · doi:10.1111/1751-2980.12659 · Cited by 54
Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis
Chandrasekhara, V., Barthet, M. A., Deviere, J. M. E., Bazerbachi, F., Lakhtakia, S., Easler, J. J., Peetermans, J. A., McMullen, E., Gjata, O., Gourlay, M. L., et al. (2020) · Endoscopy International Open · doi:10.1055/a-1243-0092 · Cited by 55
“To provide data on WON only [35], several studies had to be excluded due to the reporting of WON and pseudocyst outcomes together [11, 36, 37].”
Plasma cytokines can help to identify the development of severe acute pancreatitis on admission
Deng, L., Hu, C., Cai, W., Chen, W., Zhang, X.-X., Shi, N., Huang, W., Ma, Y., Jin, T., Lin, Z.-Q., et al. (2017) · Medicine · doi:10.1097/md.0000000000007312 · Cited by 54
Recent advances in understanding and managing acute pancreatitis
Mandalia, A. B., Wamsteker, E., & Dimagno, M. J. (2018) · F1000Research · doi:10.12688/f1000research.14244.2 · Cited by 89
Serum levels of unique miR-551-5p and endothelial-specific miR-126a-5p allow discrimination of patients in the early phase of acute pancreatitis
Kuśnierz‐Cabala, B., Nowak, E., Sporek, M., Kowalik, A., Kuźniewski, M., Enguita, F. J., & Stępień, E. Ł. (2015) · Pancreatology · doi:10.1016/j.pan.2015.05.475 · Cited by 54

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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