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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Fluid resuscitation in acute pancreatitis
Yang, A. L., & Vege, S. S. (2023) · Current Opinion in Gastroenterology · doi:10.1097/mog.0000000000000959 · Cited by 11
Disulfiram relieves severe acute pancreatitis by inhibiting GSDMD‐dependent NETs formation
Ling, X., Nie, C., Sheng, L., Han, C. Q., & Ding, Z. (2023) · Journal of Digestive Diseases · doi:10.1111/1751-2980.13211 · Cited by 11
Non-pancreatic hyperlipasemia: A puzzling clinical entity
Feher, K. E., Tornai, D., Vitális, Z., Dávida, L., Sipeki, N., & Papp, M. (2024) · World Journal of Gastroenterology · doi:10.3748/wjg.v30.i19.2538 · Cited by 13
“…of the following three criteria: (1) Upper abdominal pain; (2) serum amylase and/or lipase elevated at least three times the upper limit of normal (ULN); and/or (3) characteristic findings from abdominal imaging [computer tomography (CT), magnetic resonance imaging (MRI), and ultrasonography][2].”
Influential
Tailored Hydration With Lactated Ringer's Solution for Postendoscopic Retrograde Cholangiopancreatography Pancreatitis Prevention: A Randomized Controlled Trial
Cho, E., Kim, S., Park, C., Yoon, J. H., Lee, S. O., Kim, T. H., & Chon, H. K. (2024) · The American Journal of Gastroenterology · doi:10.14309/ajg.0000000000002903 · Cited by 11
“Early aggressive ﬂ uid resuscitation in acute pancreatitis has been considered bene ﬁ cial for a long time (17).”
Predicting Severity of Acute Pancreatitis—Evaluation of Neutrophil-to-Lymphocyte Count Ratio as Emerging Biomarker: A Retrospective Analytical Study
Vincent, A., & Shashirekha, C. A. (2024) · Cureus · doi:10.7759/cureus.74881 · Cited by 11
Pancreatic Endotherapy and Necrosectomy
Pannala, R., & Ross, A. S. (2015) · Current Treatment Options in Gastroenterology · doi:10.1007/s11938-015-0048-9 · Cited by 11
External Validation of a Predictive Model for Acute Pancreatitis Risk in Patients with Severe Hypertriglyceridemia
Morkos, M., Amblee, A. P., Henriquez, A., Basu, S., & Fogelfeld, L. A. (2019) · Endocrine Practice · doi:10.4158/ep-2018-0599 · Cited by 11
Recent Advances in Diagnosis and Severity Assessment of Acute Pancreatitis
Paul, J. (2020) · Prague Medical Report · doi:10.14712/23362936.2020.6 · Cited by 11
“15–20% of acute pancreatitis patients develop severe disease and have prolonged hospital stay (Forsmark and Baillie, 2007; Tenner et al., 2013; Greenberg et al., 2016), and 20 to 30 percent of AP patients develop complications such as necrosis, organ failure, or both (Mayer et al., 1985; Thomson,…”
Background
What should we trust to define, predict and assess pancreatic fistula after pancreatectomy?
Tzedakis, S., Sauvanet, A., Schiavone, R., Razafinimanana, M., Cauchy, F., Rouet, J., Dousset, B. E., & Gaujoux, S. (2020) · Pancreatology · doi:10.1016/j.pan.2020.10.036 · Cited by 11
Acute pancreatitis secondary to hypertriglyceridemia
Munoz, M. A., Sathyakumar, K., & Babu, B. A. (2020) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.87a.19156 · Cited by 11
Acute pancreatitis: predictors of mortality, pancreatic necrosis and intervention
Prajapati, R. P., Manay, P., Sugumar, K., Rahandale, V., & Satoskar, R. (2021) · Turkish Journal of Surgery · doi:10.47717/turkjsurg.2021.5072 · Cited by 11
“Severe acute pancreatitis (SAP) develops in 15-25% of the patients diagnosed with AP (11).”
Background
Impacts of body composition parameters and liver cirrhosis on the severity of alcoholic acute pancreatitis
Jang, D. K., Ahn, D.-W., Lee, K. L., Kim, B. G., Kim, J. W., Kim, S. H., Kang, H. W., Lee, D. S., Yoon, S. H., Park, S. J., et al. (2021) · PLoS ONE · doi:10.1371/journal.pone.0260309 · Cited by 11
Finding Predictors of Azathioprine-Induced Pancreatitis in Patients With Inflammatory Bowel Disease
Freitas, M., Capela, T. L., Silva, V. M., Arieira, C., Gonçalves, T. C., de Castro, F. D., Moreira, M. J., Machado, J. F., & Cotter, J. B. (2022) · Pancreas · doi:10.1097/mpa.0000000000002012 · Cited by 11
Pancreatic colonization of fungi in the development of severe acute pancreatitis
Otsuka, Y., Kamata, K., Minaga, K., Watanabe, T., & Kudo, M. (2022) · Frontiers in Cellular and Infection Microbiology · doi:10.3389/fcimb.2022.940532 · Cited by 11
“It is because meta-analysis using seven randomized controlled trials showed no significant improvement with prophylactic anti-microbial therapy in both mortality or infectious complication rates in SAP (Tenner et al., 2013; Crockett et al., 2018; Leppäniemi et al., 2019; Takada et al., 2022).”
BackgroundMethod
Aggressive intravenous hydration protocol of Lactated Ringer’s solution benefits patients with mild acute pancreatitis: A meta-analysis of 5 randomized controlled trials
Wu, F., She, D., Ao, Q., Zhang, S., & Li, J. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.966824 · Cited by 11
Development and external validation of a nomogram for prediction of post-endoscopic retrograde cholangiopancreatography pancreatitis
Fukuda, R., Hakuta, R., Nakai, Y., Hamada, T., Takaoka, S., Tokito, Y., Suzuki, Y., Oyama, H., Kanai, S., Noguchi, K., et al. (2023) · Pancreatology · doi:10.1016/j.pan.2023.08.008 · Cited by 11
Severe acute pancreatitis in the community: confusion reigns
Dua, M. M., Worhunsky, D. J., Tran, T. B., Rumma, R. T., Poultsides, G. A., Norton, J. A., Park, W. G., & Visser, B. C. (2015) · Journal of Surgical Research · doi:10.1016/j.jss.2015.04.054 · Cited by 11
Beneficial effects of fluid resuscitation via the rectum on hemodynamic disorders and multiple organ injuries in an experimental severe acute pancreatitis model
Chen, Y., Ma, L., Song, X., Fei, J., Chen, E., & Mao, E. (2015) · Pancreatology · doi:10.1016/j.pan.2015.09.001 · Cited by 11
Mean platelet volume in patients with biliary and non-biliary acute pancreatitis.
Okuturlar, Y., Soylu, A., Doğan, H., Cakmak, S., Utku, İ. K., Öztosun, B., Akarsu, C., Serın, S. O., Avcı, A., Köneş, O., et al. (2015) · Europe PMC (PubMed Central) · Cited by 11
High-Dose Prednisone for Treatment of Autoimmune Pancreatitis in a Patient with Coronavirus Disease 2019 (COVID-19) due to Infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
Liaquat, H., Shupp, B., Kapoor, S., & Matin, A. (2020) · American Journal of Case Reports · doi:10.12659/ajcr.926475 · Cited by 11
“This regimen is the most frequently used minimally invasive form of therapy, especially when compared with endoscopic drainage, because percutaneous drainage is successful in avoiding open necrosectomy, which is associated with higher morbidity and mortality rates [10].”
Background
Pretreatment HLADQA1-HLADRB1 Testing for the Prevention of Azathioprine-Induced Pancreatitis in Inflammatory Bowel Disease: A Prospective Cohort Study
Wilson, A. S., Wang, Q., Choi, Y., Ponich, T. P., Gregor, J. C., Chande, N., Yan, B., Sey, M. S. L., Beaton, M. D., & Kim, R. B. (2021) · Clinical and Translational Gastroenterology · doi:10.14309/ctg.0000000000000332 · Cited by 11
“AZAinduced pancreatitis was defined as follows: aminimum elevation in serum lipase 3 times the upper limit of normal with clinical symptoms of nausea, vomiting, and abdominal pain (15).”
Background
Mesalazine-induced acute pancreatitis: a rare adverse reaction but with important therapeutic implications in ulcerative colitis
Correia, J., Ponte, A. I. L., Silva, J. C., Gomes, A. C., & Afecto, E. (2021) · European Journal of Gastroenterology & Hepatology · doi:10.1097/meg.0000000000001901 · Cited by 11
Discrimination between Pancreatic Cancer, Pancreatitis and Healthy Controls Using Urinary Polyamine Panel
Nissinen, S. I., VENÄLÄINEN, M. K., Kumpulainen, P. S., Roine, A., Häkkinen, M. R., Vepsäläinen, J., Oksala, N., & Rantanen, T. K. (2021) · Cancer Control · doi:10.1177/10732748211039762 · Cited by 11
“All acute pancreatitis cases were later reviewed from hospital documents and confirmed according to the American College of Gastroenterology Guideline 2013.(20) Chronic pancreatitis was diagnosed by a clinician based on symptoms (abdominal pain, diarrhoea or weight loss), laboratory tests and CTorMRI scan with finding…”
Background
Development of Quality Measures for Acute Pancreatitis: A Model for Hospital-Based Measures in Gastroenterology
Mosko, J. D., Leiman, D. A., Ketwaroo, G. A., & Gupta, N. (2019) · Clinical Gastroenterology and Hepatology · doi:10.1016/j.cgh.2019.11.033 · Cited by 11
Akute Pankreatitis
Hecker, M., Mayer, K., Askevold, I. H., Collet, P., Weigand, M. A., Krombach, G. A., Padberg, W. M., & Hecker, A. (2014) · Der Anaesthesist · doi:10.1007/s00101-014-2307-x · Cited by 11
UEG Week 2019 Poster Presentations
Jaeger, M.-C., Guiraud, L., Rolland, C., Rolland, C., Belot, A., Sebbag, M., Bermúdez‐Humarán, L. G., Langella, P., Vergnolle, N., & Deraison, C. (2019) · United European Gastroenterology Journal · doi:10.1177/2050640619854671 · Cited by 11
Chlorogenic acid reduces inflammation in murine model of acute pancreatitis
Tarasiuk, A., Bulak, K., Talar, M., & Fichna, J. (2021) · Pharmacological Reports · doi:10.1007/s43440-021-00320-5 · Cited by 10
PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK
Collaborative, P. S., Kosti, A., Borakati, A., Varma, A., Gupta, A., Mustafa, A., Hakeem, A. R., Quddus, A., Sahl, A. B., Beniwal, A., et al. (2023) · BJS Open · doi:10.1093/bjsopen/zrad008 · Cited by 10
“…for the majority, the variation in aetiology and unpredictability of the severity mean that the management of pancreatitis has significant regional, hospital, and even individual clinician inter-variability, despite a number of guidelines issued by international professional bodies 1,6–9 .”
Background
Risk Factors of Postoperative Acute Pancreatitis and Its Impact on the Postoperative Course after Pancreaticoduodenectomy—10 Years of Single-Center Experience
Gajda, M., Grudzińska, E., Szmigiel, P., Czopek, P., Rusinowski, C., Putowski, Z., & Mrowiec, S. (2023) · Life · doi:10.3390/life13122344 · Cited by 10
“Similarly, in another study, postoperative hyperamylasemia (measured on POD 0) had a positive correlation with patients’ BMI [17].”
Result
The Clinical Characteristics and Outcomes of Acute Pancreatitis Are Different in Elderly Patients: A Single-Center Study over a 6-Year Period
Zhang, S., Chen, Z., Hu, C., Zhu, P., Jin, T., Li, L., Lin, Z., Shi, N., Zhang, X.-X., Xia, Q., et al. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13164829 · Cited by 10
“The management of patients with AP was based on the International Association of Pancreatology and the American Pancreatic Association Guidelines [23,24].”
Method
Machine Learning–Guided Fluid Resuscitation for Acute Pancreatitis Improves Outcomes
Kong, N., Chang, P. W., Shulman, I. A., Haq, U., Amini, M. M., Nguyen, D. D., Khan, F., Narala, R., Sharma, N., Wang, D., et al. (2025) · Clinical and Translational Gastroenterology · doi:10.14309/ctg.0000000000000825 · Cited by 10
“We theorize that this represents the in ﬂ uence of 2 decades of guidance favoring indiscriminate aggressive initial resuscitation of AP as codi ﬁ ed in several clinical practice guidelines (28,29).”
Constructing a prediction model for acute pancreatitis severity based on liquid neural network
Cao, J., Long, S., Liu, H., Chen, F., Liang, S., Fang, H., & Liu, Y. (2025) · Scientific Reports · doi:10.1038/s41598-025-01218-5 · Cited by 10
Evaluation of socioeconomic and healthcare disparities on same admission cholecystectomy after endoscopic retrograde cholangiopancreatography among patients with acute gallstone pancreatitis
Chouairi, F. K., McCarty, T. R., Hathorn, K., Sharma, P., Aslanian, H. R., Jamidar, P. A., Thompson, C. C., & Muniraj, T. (2021) · Surgical Endoscopy · doi:10.1007/s00464-020-08272-2 · Cited by 10
“Gastroenterology societies in the United States and abroad, including the American Gastroenterology Association (AGA), American College of Gastroenterology (ACG), as well as the International Association of Pancreatology (IAP) and American Pancreatic Association (APA) recommend CCY during the initial admission rather…”
Background
Accuracy of angiopoietin-2 for predicting organ failure in patients with acute pancreatitis: a systematic review and meta-analysis
Lv, Y.-C., Yao, Y., Liu, Q., & Lei, J.-J. (2021) · Journal of International Medical Research · doi:10.1177/0300060520986708 · Cited by 10
National recurrence of pancreatitis and readmissions after biliary pancreatitis
Rios-Diaz, A. J., Lamm, R. J., Metcalfe, D., Devin, C. L., Pucci, M. J., & Palazzo, F. (2022) · Surgical Endoscopy · doi:10.1007/s00464-022-09153-6 · Cited by 10
AGI grade-guided chaiqin chengqi decoction treatment for predicted moderately severe and severe acute pancreatitis (CAP trial): study protocol of a randomised, double-blind, placebo-controlled, parallel-group, pragmatic clinical trial
Chen, Z., Yang, X., Guo, J., Jin, T., Lin, Z., Zhu, P., Li, J., Li, L., Sun, X., Du, D., et al. (2022) · Trials · doi:10.1186/s13063-022-06792-x · Cited by 10
“Conventional treatment regimen All patients will receive standard treatment according to recently published guidelines [7, 8], including fluid therapy, nutritional supplementation, routine medical treatment such as proton pump inhibitors, analgesia and antibiotics as indicated, organ supportive therapy, and ERCP if ne…”
BackgroundMethod
National trends and clinical outcomes of interventional approaches following admission for infected necrotizing pancreatitis in the United States
Tran, Z. K., Xu, J., Verma, A., Ebrahimian, S., Cho, N. Y., Benharash, P., & Burruss, S. K. (2023) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000003934 · Cited by 10
“With a paradigm shift in the management of infected pancreatic necrosis, examination of modern treatment approaches at the national level is warranted.(5,6,19) The present study revealed that, for patients requiring interventions, moreweremanaged only with drainage procedures.”
Background
Clinical treatment for persistent inflammation, immunosuppression and catabolism syndrome in patients with severe acute pancreatitis (Review)
Zhang, B., Xiao, Q., Ma, Q., & Han, L. (2023) · Experimental and Therapeutic Medicine · doi:10.3892/etm.2023.12194 · Cited by 11
Regional Cost Variation for Acute Pancreatitis in the U.S.
Yeh, J. L., Su, W., & Wu, B. U. (2014) · PubMed · doi:10.6092/1590-8577/2797 · Cited by 10
Nutrition and metabolic support for critically ill patients
Mahanna, E., Crimi, E., White, P., Mann, D. S., & Fahy, B. G. (2015) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0000000000000172 · Cited by 10
Walled-off pancreatic necrosis: where are we?
Boškoski, I., & Costamagna, G. (2014) · Europe PMC (PubMed Central) · Cited by 10
Acute pancreatitis with normal lipase and amylase: an ED dilemma
Agrawal, A., Parikh, M., Thella, K., & Jasdanwala, S. (2016) · The American Journal of Emergency Medicine · doi:10.1016/j.ajem.2016.05.023 · Cited by 10
Approach to the Patient With Hematochezia
Cotter, T. G., Buckley, N. S., & Loftus, C. G. (2017) · Mayo Clinic Proceedings · doi:10.1016/j.mayocp.2016.12.021 · Cited by 10
Protective effects of tropisetron on cerulein-induced acute pancreatitis in mice
Rahimian, R., Zirak, M. R., Seyedabadi, M., Keshavarz, M., Rashidian, A., Kazmi, S., Jafarian, A. H., Karimi, G., & Mousavizadeh‬, K. (2017) · Biomedicine & Pharmacotherapy · doi:10.1016/j.biopha.2017.06.067 · Cited by 10
“AP is an inflammatory disorder of pancreas which appears to be rising during last decades and causes a significant mortality [2].”
Background

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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