Understanding the New Guidelines for Acute Pancreatitis: A Patient's Guide

This year, the American College of Gastroenterology (ACG) published new guidelines for patients with acute pancreatitis (AP). This guide summarizes these guidelines to help you understand the standard of care and evaluate if the care provided meets these standards or if a transfer to a specialized center is needed.


What is Acute Pancreatitis?

Acute pancreatitis is the inflammation of the pancreas, an organ crucial for digestion and blood sugar regulation. It's a common cause of hospital admissions in the U.S. and can vary greatly in severity. While most patients recover within a few days, about 20% may develop serious complications like pancreatic necrosis or organ failure.
 

Key Points of the Guidelines
 
Diagnosis
 

• Imaging: Routine CT scans at admission are not recommended unless the diagnosis is unclear or there is no improvement after 48-72 hours.

 
Causes of Acute Pancreatitis
 

• Biliary Pancreatitis: Often related to gallstones. An ultrasound is recommended to detect gallstones.
• Idiopathic Pancreatitis: Further investigation with MRI or endoscopic ultrasound is suggested if the cause is unknown after the initial tests.
• Other Causes: High triglycerides or potential pancreatic tumors should be considered, especially in patients over 40 with recurrent episodes.

 
Initial Assessment and Risk Stratification
 

• Risk Factors: Key risk factors for severe disease include elevated blood urea nitrogen (BUN), hematocrit (HCT), obesity, and comorbidities. Patients with organ failure or systemic inflammatory response syndrome (SIRS) should be closely monitored.

 
Initial Management
 

• Fluid Resuscitation: Early and moderately aggressive hydration with lactated Ringer's solution is recommended. Fluid levels should be frequently reassessed to prevent complications.

 
Endoscopic Retrograde Cholangiopancreatography (ERCP)
 

• ERCP Timing: Early ERCP (within 24 hours) is advised for patients with biliary pancreatitis complicated by cholangitis. For others, ERCP should be considered only if other imaging confirms common bile duct (CBD) stones.

 
Preventing Post-ERCP Pancreatitis
 

• Medications: Rectal indomethacin is recommended for high-risk patients, and a pancreatic duct stent may be considered to prevent post-ERCP pancreatitis.

 
The Role of Antibiotics
 

• Antibiotic Use: Prophylactic antibiotics are not recommended for severe AP. However, antibiotics are crucial for treating infected pancreatic necrosis, ideally delaying any drainage procedures until after 4 weeks.

 
Nutrition in Acute Pancreatitis
 

• Early Feeding: Early oral feeding (within 24-48 hours) with a low-fat diet is suggested for mild AP. For more severe cases, enteral nutrition (feeding through a tube) is preferred to prevent complications. Parenteral nutrition (intravenous feeding) should be avoided unless absolutely necessary.

 
Surgery in Acute Pancreatitis
 

• Cholecystectomy: Patients with mild acute biliary pancreatitis should undergo gallbladder removal before discharge.
• Minimally Invasive Techniques: Preferred for debridement and necrosectomy in stable patients, with surgical interventions ideally delayed until the collection walls have matured (about 4 weeks).

 
Conclusion

These guidelines provide a comprehensive approach to managing acute pancreatitis, emphasizing early diagnosis, appropriate risk stratification, timely interventions, and careful monitoring. If you or a loved one is being treated for AP, ensure that the care aligns with these evidence-based recommendations. If necessary, seek specialized care to optimize outcomes.
 
By understanding these guidelines, you can better advocate for yourself or your loved ones during treatment for acute pancreatitis.
 

Contributors to the Guidelines

The guidelines were developed by experts from:

• Mayo Clinic, Rochester, Minnesota
• Beth Israel Deaconess Medical Center, Boston, Massachusetts
• University of Virginia
• Weill Cornell Medicine, New York City
• University of California, San Diego
• Dartmouth-Hitchcock Medical Center, New Hampshire

by Tossapol Kerdsirichairat, MD, FASGE
Clinical Associate Professor of Medicine
Advanced/Bariatric Endoscopy, Digestive Disease Center
Bumrungrad International Hospital