Guideline Pancreatite 2013 AJG

8/18/2019 Guideline Pancreatite 2013 AJG

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00 PRACTICE GUIDELINES nature publishing group

ME

American College of Gastroenterology Guideline:

Management of Acute Pancreatitiscott Tenner, MD, MPH, ACG!, "ohn #aillie, M#, Ch#, $CP, ACG% , "ohn De&itt, MD, ACG' and Santhi S(aroop )ege, MD, ACG*

his guideline presents rec!!end"tins #r the !"n"ge!ent # p"tients $ith "cute p"ncre"titis %AP&' During the p"st

ec"de( there h")e *een ne$ underst"ndings "nd de)elp!ents in the di"gnsis( etilg+( "nd e"rl+ "nd l"te !"n"ge!ent

the dise"se' As the di"gnsis # AP is !st #ten est"*lished *+ clinic"l s+!pt!s "nd l"*r"tr+ testing( cntr"st,

nh"nced c!puted t!gr"ph+ %CECT& "nd- r !"gnetic resn"nce i!"ging %MRI& # the p"ncre"s shuld *e reser)ed #r

"tients in $h! the di"gnsis is uncle"r r $h #"il t i!pr)e clinic"ll+' .e!d+n"!ic st"tus shuld *e "ssessed

!!edi"tel+ upn present"tin "nd resuscit"ti)e !e"sures *egun

s needed' P"tients $ith rg"n #"ilure "nd- r the s+ste!ic in#l "!!"tr+ respnse s+ndr!e %SIRS& shuld *e "d!itted

"n intensi)e c"re unit r inter!edi"r+ c"re setting $hene)er pssi*le' Aggressi)e h+dr"tin shuld *e pr)ided t "ll

"tients( unless c"rdi)"scul"r "nd- r ren"l c!r*idites preclude it' E"rl+ "ggressi)e intr")enus h+dr"tin is !st

ene#i ci"l $ithin the #i rst 1//4 h( "nd !"+ h")e little *ene#i t *e+nd' P"tients $ith AP "nd cncurrent "cute

hl"ngitis shuld underg endscpic retrgr"de chl"ngip"ncre"tgr"ph+ %ERCP& $ithin /4 h # "d!issin'

"ncre"tic duct stents "nd- r pstprcedure rect"l nnsterid"l "nti,in#l "!!"tr+ drug %NSAID& suppsitries shuld

e utilied t l$er the ris2 # se)ere pst,ERCP p"ncre"titis in high,ris2 p"tients' Rutine use # prph+l"ctic

nti*itics in p"tients $ith se)ere AP "nd- r sterile necrsis is nt rec!!ended' In p"tients $ith in#ected necrsis(

nti*itics 2n$n t penetr"te p"ncre"tic necrsis !"+ *e use#ul in del"+ing inter)entin( thus decre"sing !r*idit+

nd !rt"lit+' In !ild AP( r"l #eedings c"n *e st"rted i!!edi"tel+ i# there is n n"use" "nd )!iting' In se)ere AP(

nter"l nutritin is rec!!ended t pre)ent in#ectius c!plic"tins( $here"s p"renter"l nutritin shuld *e ")ided'

s+!pt!"tic p"ncre"tic "nd- r e3tr"p"ncre"tic necrsis "nd- r pseudc+sts d nt $"rr"nt inter)entin reg"rdless

# sie( lc"tin( "nd- r e3tensin' In st"*le p"tients $ith in#ected necrsis( surgic"l( r"dilgic( "nd- r endscpic

r"in"ge shuld *e del"+ed( pre#er"*l+ #r 4 $ee2s( t "ll$ the de)elp!ent # " $"ll "rund the necrsis'

m J Gastroenterol %+!' !+-:!*++.!*!/ doi:!+0!+'-1a2g0%+!'0%!- published online '+ "uly %+!'

cute pancreatitis 3AP4 is one of the most common diseases of

e gastrointestinal tract, leading to tremendous emotion5al,

hysical, and 6 nancial human burden 3!,%40 7n the 8nited States,

%++9, AP (as the most common gastroenterology discharge

agnosis (ith a cost of %0 billion dollars 3%40 $ecent studies

o( the incidence of AP ;aries bet(een *09 and


2/127


3/127

0/ Tenner et al.

T"*le /' Su!!"r+ # rec!!end"tins

Diagnosis

!0 The diagnosis of AP is most often established by the presence of t(o of the three follo(ing criteria: 3i4 abdominal pain consistent (ith the disease,3ii4 serum amylase and1or lipase greater than three times the upper limit of normal, and1or 3iii4 characteristic fi ndings from abdominal imaging3strong recommendation, moderate Ouality of e;idence40

%0 Contrast5enhanced computed tomographic 3C=CT4 and1or magnetic resonance imaging 3M$74 of the pancreas should be reser;ed for patients in(hom the diagnosis is unclear or (ho fail to impro;e clinically (ithin the fi rst *-.A should be gi;en 3strong recommendation, lo( Ouality of e;idence40

Table % continued on the follo(ing page

The A!eric"n 8urn"l # GAST$I=>T=$IIG )I8M= !+- J S=PT=M#=$ %+!' $$$'"!9g"str'c!


4/127


5/127

04 Tenner et al.

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etiology

of AP

can be

readily

establis

hed inmost

patient

s0 ?e

most

commo

n

cause

of AP is

gallston

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enti6

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ould

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olecyecto

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psis

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allsto

ncre

tis is

ually

ute

ent

d

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(hen

e

one ismo;e

or

sses

onta

ously

Alcoh

duced

ncrea

s o

en

anifes

as a

spectru

m,

ranging

from

discrete

episode

s of AP

to

chronic

irre;ersi

ble

silent

change

s0 ?e

diagnos

is

should

not be

entertai

ned

unless

a

person

has a

history

of o;er

/ years

of

hea;y

alcohol

consum

ption

3'!40

Hea;yN

alcohol

consum

ption is

generall

y

conside

red to

be /+g

per day,

but is o

Ken

much

higher

3'%40

Clinicall

y

e;ident

AP

occurs

in L /K

of

hea;y

driners

3''4

thus,there

are


8/127

ely

her

ctors

at

nsiti@

di;idu

s to

e

ects

cohol,

ch as

netic

ctors

d

bacco

e


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g1dl to

nsider

the

use of

P

-,'940

ctesce

ily4

rum

s

en

ser;e

in as

any as

K of

tients

th AP,

d

erefor

a

sting

glyceri

le;el

ould

re5

aluate

!

onth a

er

scharg

(hen

pertriycerid

mia is

spect

3*+40

houg

most

not,

y

nign

aligna

mass

at

struct

the

ain

ncrea

can

sult in

P0 7t

s

en

timate

that

!*K

tients

(ith

benign

or

maligna

nt

pancreat

obiliary

tumors

present

(ith

apparen

t 7AP

3*!.

*' 40

His5

torically,

adenoca

rcinoma

of the

pancrea

s (as

consider

ed a dis5

ease of

old age0

Ho(e;e

r,

increasi

ngly

patients

in their

*+s

and

occasio

nallyyounger

are

presenti

ng (ith

pancreat

ic

cancer0

?is entity

should

be

suspect

ed in

any

patient

*+ years

of age

(ith

idiopathi

c

pancreat

itis,

especiall

y those

(ith a

prolonged or


10/127


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ultidis

plinar

proac

Anato

c and

ysiol

ic

omali

of

e

ncrea

occur

!+.

K of

e

pulati

,

cludin

ncrea

;isum

d

hinct

of

ddi

sfunc

n

-40 7t

mains

ntro;

sial if

esesorder

alone

use

P 3*940

re

ay be

mbin

on of

ctors,

cludin

atomi

and

netic,

at

edisp

e to

e

;elop

ent of

P in

scept

e

di;idus 3*-40

dosc

opic

therapy,

focusin

g on

treating

pancrea

s

di;isum

and1or

sphinct

er of

Iddi

dysfunc

tion,

carries

a signi6

cant

ris of

precipit

ating

AP and

should

beperform

ed only

in

speciali

@ed

units

3/+,/!40

?e in

Bu5ence

of

genetic

defects,such as

cationic

trypsino

gen

mutatio

ns,

SP7>,

or

CT$

mutatio

ns, in

causing

AP is

being

increasi

ngly

recogni

@ed0 ?

ese

defects,

further

more,

may

also

increase the

ris of


12/127

P in

tients

th

atomi

omali

,

ch as

ncrea

;isum

-40

o(e;e

the

e of

netic

sting

AP

s yet

be

termi

d, but

ay beeful

tients

th

ore

an

e

mily

embe

(ith

ncrea

sease

*40

di;idu

s (ith

P and

family

story

ncrea

sease

ould

ferred

r

rmal

netic

unsel

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8MM$

=)7D=>C=De#initin #se)ereAP

Most

episode

s of AP

are mild

and

self5

limiting,

needing

only

brief

hospitali

@ation0

Mild AP

is de6

ned by

the

absenc

e of

organ

failure

and1or

pancrea

tic

necrosi

s 3/,40

#y *- h

aKer

admissi

on,

these

e A!eric"n 8urn"l

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ould

;e

bsta

ally

pro;

and

gun

feedi0 7n

tient

s (ith

se;ere

disease,t(o

phases

of AP

are

recogni@

ed: early

3(ithin

the 6 rst

(ee4

and late0

ocal

compli5

cations

include

peripanc


17/127

atic B

d

llecti

s

d

ncre

c

d

ripan

eatic

crosi

erile

ecte

ost

tient

(ith

;ere

seas

esentthe

merg

cy

om

th no

gan

lure

ncre

c

crosi

fortutely,

s

s led

any

rors

nical

anag

ment

this

seas3/%40

se

rors

clude

lure

o;ide

eOua

drati

,

lure

agno

and

treat

cholangi

tis, and

failure to

treat

early

organ

failure0

or this

reason,

it is

critical

for the

clinician

to

recogni@

e the

impor5

tance of

not

falsely

labeling

a patient(ith mild

disease

(ithin

the 6rst

*- h o f

admissio

n for AP0

Se;er

e AP

occurs

in !/.

%+K of

patients

3/'40

Se;ere

AP is

de6ned

by the

presenc

e of

persiste

nt 3fails

to

resol;e

(ithin *-h4 organ

failure

and1or

death

340

Historica

lly, in the

absence

of organ

failure,

local

complica

tionsfrom

pancreat


18/127

s,

ch

ncre

c

crosi

(ere

so

nsid

ed

;ere

seas

,/'

o(e;

ese

cal

mpli

tions

cludi

ncre

c

cro5

s (ith

thout

nsie

gan

lure4

6ne

oder

ely;ere

P

ee

*le

oder

ely

;ere

ute

ncre

tis is

aract@ed

the

esen

of

nsie

gan

lure

local

stem

c

mplitions

the

absence

of

persiste

nt organ

failure

340 An

eFample

of a

patient

(ith

moderat

ely

se;ere

acute

pancreat

itis is

one (ho

has

peripanc

reatic B

uid

collectio

ns andprolonge

d

abdomin

al pain,

leuocyt

osis

and,

fe;er,

causing

the

patient

to

remainhospitali

@ed for


19/127

th

croti

ng

ncre

tis, it

then

nsid

ed

;ere

seas

Irga

lure

d

e;io

ly

en

6ned

oc

ystoli

ood

essu

L 9+

m

g4,

lmo

ry

suRc

ncy

aI%

+m

Hg4,

nallure

reati

ne

mg1

aK

hydr

on4,

d1or

stroi

estin

eedi

g 3

+ ml

ood

ss1%*

'40

e;ise

lanta

iterino(

6ne

organ

failure

as a

score of

% or

more for

one of

these

organ

systems

usingthe

modi6ed

Marshal

l scoring

system

3,-40 ?

e

authors

feel that

rather

than

calculat

e a

Marshal

score

3(hich

may be

compleF

for the

busy

clinician

4,

relying

on the

older Atlanta

de6

nitions

(ould

be as

useful0

urther

study is

needed

to

;alidate

the

need for using

the

Marshal

score0Pancr

eatic

necrosis

is de6

ned as

diEuse or

focal

areas of non5

;iable


20/127

ncre

c

renc

ma

cm in

e or

'+K

the

n5

eas

'40

ncre

c

crosi

can

erile

ected

scus

d

lo(40

the

senc

of

ncre

c

crosi

in

d

sease

e

emat

s

ncre

is

6ned

erstiti

ncre

tis0

houg

there

some

rrelati

t(ee

ectio

ncre

c

crosi

spital

ngth

stay,

dgan

ure,

both

patients

(ith

sterile

necrosis

and

infected

necrosis

may

de;elop

organ

failure

3//,/40

?e

presence

of

infection

(ithin

the

necrosis

probably

does not

increase

the

lielihood

of

present

or future

organ

failure0

Patients

(ith

sterile

necrosis

can

suEer

from

organ

failure

and

appear

as ill

clinically

as those

patients

(ith

infectednecrosis0

Persisten

t organ

failure is

no( de6

ned by a

Modi6ed

Marshal

Score

3,-40


21/127

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P n

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at

ads to

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59/127

other disease

states to lead to

better electro5lyte

balance and

impro;ed

outcomes 3-9,9+40

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disease in order to

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centrally placed

catheter is m

commonly use

determine ;ol

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data indicate

the intrathor

blood ;ol

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than cen

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Measurement

intrathoracic b

;olume indeF

therefore a

more accu

assessment

;olume status

patients mana

in the inten

care unit0 Patie

not respond5in

intra;enous

hydration e

3(ithin .!%

may not be

from contin

aggressi;e

hydration0


60/127

=$CP 7> AP?e role of =$CP

in AP is related to

the management

of choledo5

cholithiasis0

Although =$CPcan be used to

identify

pancreatic ductal

disruption in

patients (ith

se;ere AP,

possibly leading

to inter;entions

for the so5called

dislocated duct

syndrome, a

consensus hasne;er emerged

that =$CP should

be performed

routinely for this

purpose 3/%40

Recommendatio

ns

!0 Patients (ith

AP and

concurrent

acute

cholangitisshould

undergo

=$CP (ithin

%* h of

admission

3strong

recommen5

dation,

moderate

Ouality of

e;idence40

%0 =$CP isnot

needed

early in

most

patients

(ith

gallstone

pancreati

tis (ho

lac

laborator

y or

clinicale;idence

of

ongoing

biliary

obstructi

on

3strong

recomme

ndation,

moderate

Ouality of

e;idence

40'0 7n the absenc

of cholangiti

and1or

2aundice,

M$CP or

=8S rather

than

diagnostic

=$CP

should be

used to

screen forcholedocho

hiasis if

highly

suspected

3conditional

recommend

tion,

moderate

Ouality of

e;idence40

*0 Pancreatic

duct stents

and1or

postproced

e rectal no

steroidal

anti5

inBammato

drug

3>SA7D4

suppositor

s should be

utili@ed to

lo(er theris of

se;ere pos

=$CP

pancreatiti

in high5ris

patients

3conditiona

recommen

5tion,

moderate

Ouality of

e;idence40


61/127

TH= $I= I=$CP 7> APortunately, most

gallstones that

cause AP readily

pass to the

duodenum and

are lost in the

stool 39%40

Ho(e;er in a

minority of

patients,

persistent

choledocholithiasi

s can lead to

ongoing

pancreatic duct

and1or biliary tree

obstruction,

leading to se;ere

AP and1or

cholangitis0

$emo;al of obstructing

gallstones from

the biliary tree in

patients (ith AP

should reduce the

ris of de;eloping

these

complications0

?ere ha;e been

se;eral clinical

trials performed to

ans(er the

Ouestion: does

early =$CP 3(ithin

%*.eoptolemos et

al. 39'4 studied

!%! patients (ithprobable acute

biliary pancreatitis,

strati56ed for

se;erity according

to the modi 6ed

Glasgo( criteria0

?e trial (as

performed in

single center in

8nited ingd

Patients

predicted se;

AP had fe

complications

they under(

=$CP (ithin <

of admission 3%

;s0 !K, P L+0

&hen pati

(ith concur

acute cholan

3(ho (

ob;iously be

from early =$

(ere eFcluded,

diEerence

remained s

cant 3!/K

!K, P W+0+

Mortality (as signi6cantly

Eerent in the

groups0 an e

39*4 reported

study of

patients

suspected bi

pancreatitis str

ed for se;

according

$ansonQs crit

Patients in study gr

under(ent =$

(ithin %* h

admission

those in

control group (

oEered

conser;ati;e

management0

control group

oEered =$CP

acute cholan

de;eloped0 ?

(ho under(

early =$CP

fe(er

complications

3!'K ;s0 /

P W+0++%40

%+!' by the American College of Gastroenterology

The A!eric"n 8urn"l # GAST$I=>T=$II


62/127

07 Tenner et al.

#ase

on

ese

udies,

(as

clear

hether tients

th

;ere

P in

e

senc

of

ute

olang

s

ne6t

mrly

$CP0

refore

olsch

al.

/4

gani@

a

ultice

er

udy of

$CP

acuteary

ncrea

s that

clude

tients

ost

ely to

ne6t,

mely

ose

th a

rum

rubin

/

g1dl0

s,

tients

th

ute

olang

s and1

;ious

arye

struct

ion

under(

ent

early

=$CP

and

(ere

not

include

d in thestudy0 ?

is study

focused

on

determi

ning the

bene 6t

of early

=$CP

in

pre;enti

ng

se;ere

AP in

the

absenc

e of

biliary

obstruct

ion0

Althoug

h this

study

has

been(idely

critici@e

d for

design

B a(s

and the

unusual

ly high

mortalit

y of

patients

(ith

mild

disease

3-K

compar

ed (ith

an

eFpecte

d !K4,

no

bene6t

in

morbidit

y and1or mortalit

y (as


63/127

en in

tients

ho

der(

t

rly

$CP0

om

s

udy, it

pears

at the

ne6t

early

$CP

seen

tients

th AP

mplic

ed by

ute

olangs and

ary

e

struct

n, but

t

;ere

P in

e

senc

of

ute

olangs0

More

cent

udies

;e

n6

ed

at

rly

$CP

thin

h of missi

creas

orbidit

and

ortalit

in

tients

th AP

mplic

ed byary

psis

39,9onin;a

si;e

imaging

studies

are the


64/127

eferre

diag5

stic

odaliti

in

ese

tients

8S

d1or

$CP40

o(e;e

it is

t

ear if

y

sting

eds

be

rform

in

tients

ho

pro;e

$=)>T7>

IST5$CPA>C=AT7S

P

mains

e

ost

mmo

mplic

on of

$CP0

stori5

lly,

s

mplic

onas

en in

!+K

ses

d in

.

K of

rtain

gh5

ocedu

s

+,9-40

;er

the past

!/

years,

the ris

of post5

=$CP

pancrea

titis has

decreas

ed to %.

*K and

the ris

of

se;ere

AP to L

!1/++

3/+,9-40

7n

general,

the

decreas

e in

post5=$CP

AP and

se;ere

AP is

related

to

increas

ed

recognit

ion of

high5

ris

patientsand

high5

ris

procedu

res in

(hich

=$CP

should

be

a;oided

and the

application of

appropri

ate

inter;en

5tions to

pre;ent

AP and

se;ere

AP

3 /+40

Patie

nts

(ithnormal

or


65/127

ear5

ormal

e

ct

nd

er

sts

a;e a

(er

eliho

d of a

mm

n bile

ct

one

nd1or

her

athol

gy

trictu

,

mor40

ese

atient

agno

c

$CP

as

rgely

een

plac

by

8S or

$CP

s the

of

ost5

$CP

ancre

tis is

eater

a

atient

th

ormal

liber e

ct

nd

ormal

irubi

dds

tio

* for

ost5

$CP

ancre

tis4

mpa

red

(ith a

patient

(ho is

2aundic

ed (ith

a

dilated

commo

n bile

duct

3odds

ratio

+0% for

post

5=$CP

pancre

atitis4

39940

urther

more,

M$CP

and=8S

are as

accurat

e as

diagno

stic

=$CP

and

pose

no ris

of

pancre

atitis

39-40or

patients

undergo

ing a

therape

utic

=$CP,

three

(ell5

stud5iedinter;en

tions to

decreas

e the

ris of

post5

=$CP

pancrea

ti5tis,

especial

lyse;ere

disease


66/127

clude:

ide(i

nnula

n,

3ii4

pancrea

tic duct

stents,

and 3iii4

rectal

>SA7Ds

0

Guide(i

re

cannula

tion

3cannul

ation of

the bile

duct

and

pancrea

tic duct

by aguide(i

re

inserted

through

a

catheter

4

decreas

es the

ris of

pancrea

titis

3!++4 by

a;oidin

g

hydrost

atic

in2ury to

the

pancrea

s that

may

occur

(ith the

use of radioco

ntrast

agents0

7n a

study of

*++

consec

uti;e

patients

randomi

@ed to

contrast

or

guide(i

re


67/127

nnula

n,

ere

ere no

ses

AP in

e

ide(i

oup

mpar

(ith

cases

the

ntrast

oup

L

++!40

more

cent

udy in

+tients

ospec

ely

ndomi

d to

ide(i

nnula

n

mpar

(ith

n;ent

nalntrast

ectio

also

und a

creas

in

st

$CP

ncrea

s in

e

ide(i

oup

+!40

o(e;e

the

ductio

in

st5

$CP

ncrea

s

ay not

tirely

ated

to

guide(i

re

cannula

5tion

3!+%4

and

may

ha;e

been

related

to less

need for

precut

sphinct

erotomy

in

patients

undergo

ing

guide(i

re

cannulation0

$egardl

ess,

guide(i

re

cannula

tion

compar

ed (ith

con;ent

ional

contrast

cannulation

appears

to

decreas

e the

ris of

se;ere

post5

=$CP

AP

3!+',!+

*40Place

ment of

a

pancrea

tic duct

stent

decreas

es the

ris of

se;ere

post5

=$CP

pancreatitis in

high5


68/127

tients

such

ose

derg

ng

mpulle

omy,

dosc

ic

hinct

of

ddi

anom

ry, or

ncrea

er;en

ns

ring

$CP0

%++<eta5

alysis

blish

by

driulli

al.

+/4,

hich

alu5

ed *

ndomi

d,

ospece

als

cludin

%-

tients

o(ed

at

ncrea

duct

ent

acemt

ords

t(o5

d

op in

e

ciden

of

st5

$CP

ncrea

s

*0!K0

K P

W +0++9

odds

ratio:

+0**,

9/K

con6

dence

inter;al:

+0%*.

+0-!40

Althoug

h

further

study is

needed,

smaller

'

rench

3r4 un

Banged

pancrea

tic

stentsappear

to lo(er

the ris

of post5

=$CP

pancrea

titis 3P W

+0++*'4,

pass

more

spontan

eously

3P W + 0+++!4,

and

cause

less

pancrea

tic

ductal

change

s 3%*K

;s0

-+K4 as

compar ed (ith

larger *

r, / r,

or r

stents

3!+40

Ho(e;e

r, ' r

pancrea

tic stent

placem

ent is

moretechnic

ally


69/127

mand

g

caus

of the

ed to

e a

ry B

py

+!-

ch

amete

ide(i

houg

ophyl

tic

ncrea

duct

enting

a

st5ecti;

ategy

r the

e;enti

of

st5

$CP

ncrea

s for

gh

s

tients+


70/127

oup

drugs

enuat

the in

mma

ry

spons

of AP

e

SA7Ds

+9,!!

0 T(o

nical

als

;e

o(n

at a

+ mg

ctal

pposi

ry of

clofen

duces

e

ciden

of

st5

$CP

ncrea

s

!!,!!

7n

di5n, a

cent

ultice

er,

uble5

nd,

randomi

@ed

placebo

controll

ed trial

of +%

patients

undergo

ing a

high5

ris

=$CP

demons

trated a

signi6

cant

reductio

n of

post5

=$CP

pancrea

ti5tis in

patients

gi;en

postpro

cedure

rectal

indomet

hacin

3!!' 40 7t

is

importa

nt to

note

that thisstudy

include

d only

patients

at a

e A!eric"n 8urn"l

AST$I=>T=$IIG

8M= !+- J S=PT=M#=$' $$$'"!9g"str'c!


71/127


high ris of

de;eloping post5

=$CP

pancreatitis and

se;ere AP, (hich

is the population

that (ould bene6t

the most0 &hen

considering the

costs, riss, and

potential bene6ts

re;ie(ed in the

published

literature, rectal

diclofenac and1or

indo5methacin

should be

considered

before =$CP,especially in

high5ris patients0

Although further

study is needed

to de6ne the

optimal dose, at

present it is

reasonable to

consider place5

ment of t(o

indomethacin /+

mg suppositories3total !++ mg4 a

Ker =$CP in

patients at a high

ris of de;eloping

post5=$CP AP0

Ho(e;er, until

further study is

performed, the

placement of

rectal >SA7Ds

does not replace

the need for a

pancreatic duct

stent in the

appropriate high5

ris patient0

TH= $I= I A>T7#7IT7CS7> AP

Recommendatio

ns

!0 Antibioticsshould be

gi;en for an

eFtrapancre

c infection,

such as

cholangitis,

catheter5

acOuired

infections,

bacteremia

urinary trac

infections,pneumonia

3strong

recommend

tion,

moderate

Ouality of

e;idence40

%0 $outine u

of

prophylact

antibiotics

patients (se;ere AP

not

recommen

d 3stro

recommen

tion,

moderate

Ouality

e;idence40'0 ? e use

of

antibio

tics inpatient

s (ith

sterile

necros

is to

pre;en

t the

de;elo

pment

of

infecte

d

necros

is is

not

recommen

ded

3strong

recommen

dation,

moderate

Ouality of

e;idence40*0 7nfected

necrosisshould be

considered


72/127

in patients

(ith

pancreatic

or

eFtrapancre

atic necrosis

(ho

deteriorate

or fail to

impro;e a

Ker A4 for

Gram stain

and cultureto guide use

of

appropriate

antibiotics or

3ii4 empiric

use of

antibiotics a

Ker

obtaining

necessary

cultures for

infectious

agents,

(ithout CT

>A, should

be gi;en

3strong

recommend

ation,

moderate

e;idence40

/0 7n patients

(ith infected

necrosis,

antibioticsno(n to

pene5trate

pancreatic

necrosis,

such as

carbapenem

s,

Ouinolones,

and

metronida@ol

e, may be

useful in

delaying or

sometimes

totally

a;oiding

inter;entio

thus

decreasing

morbidity

and morta

3conditiona

recommen

ation,

moderate

Ouality of

e;idence400 $outine

administrat

n of

antifungal

agents alon

(ith

prophylactic

or

therapeuticantibiotics i

not

recommend

ed

3conditiona

recommend

ation, lo(

Ouality of

e;idence40

In#ectiusc!plic"tin

7nfectious

complications,

both pancre

3infected necro

and

eFtrapancreatic

3pneumonia,

cholangitis,

bacteremia,

nary t

infections, and

on4, are a m

cause of morb

and mortality

patients (ith

Many infect

are hosp

acOuired and

ha;e a m

impact on mort

3!!*40 e

tachycardia,

tachypnea,

leuocytosis

associated


73/127

S7$S

that may oc

early in

course of AP m

be

indistinguishab

from se

syndrome0 &an infection

suspected,

antibiotics sho

be gi;en (

the source of

infection is be

in;es5tigated

3/'40 Ho(e

once blood

other cultures

found to

negati;e andsource

infection is ide

ed, antibio

should

discontinued0

P$=)=>T7>GTH=7>=CT7I>IST=$7=>=C$IS7S?e paradigm

K contro;ersy o

using antibio

in AP

centered

pancreatic

necrosis0 &

compared

patients

sterile necro

patients

infected

pancreatic

necrosis ha;e

higher mort


74/127

rate 3mean '+K,

range !*.9K4

3/'40 or this

reason,

pre;enting

infection of

pancreatic

necrosis is

important0

Although it (as

pre;iously

belie;ed that

infectious

complications

occur late in the

course of the

disease

3!!/,!!4, a

recent re;ie(

found that %


75/127

pre;ent infected

necrosis 3!%-40

#ecause of the

decreased

morbidity and

mortality in this

trial in patients

(ith se;ere AP

(ho had

undergone

selecti;e

decontamina5tion,

further study in

this area is

needed0 inally,

probiotics should

not be gi;en

se;ere

Although ea

trials suggeste

benefit, a ;

(ell5conducted

randomi@ed c

trolled clinical

demonstrated

increased

mortality 3!

This lac

benefit has a

been sho(n

recent m

analysis 3!'+4



1410 Tenner etal.

In#ectednecrsis

$ather

than

pre;enting

infection,

the role of

antibiotics

in patients

(ith

necroti@ing

AP is no(to treat

established

infected

necro5sis0

?e concept

that

infected

pancreatic

necrosis

reOuires

prompt

surgicaldebrideme

nt has also

been

challenged

by multiple

reports and

case series

sho(ing

that

antibiotics

alone can

lead to

resolu5tion

of infection

and, in

selec

patie

a;oid

surgealtog

er 3!

!'*40

Garg

al. 3!

repor

*


76/127

?e same

group

published a

meta5

analysis of

- studies

in;ol;ing

*+9

patients

(ith

infected

necrosis of

(hom '%*

(ere

successfull

y treated

(ith

antibiotics

alone

3!'/40

I;erall,

*K of the

patients(ith

infected

necrosis in

this meta5

analysis

could be

managed

by

conser;ati;

e antibiotic

treatment

(ith !%Kmor5tality,

and only

%K

under(ent

surgery0

?us, a

select

group of

relati;ely

stable

patients

(ith

infected

pancreatic

necrosis

could be

managed

by

antibiotics

alone

(ithout

reOuiring

percutane5

ous

drainage0Ho(e;er, it

should be

cauti

d

these

patie

reOui

close

supe

on

percu

eous

endo

pic

necro

ctom

shou

be

cons

ed if

patie

fails

impro

or

detertes

clinic

TH=$II C>AThe

techn

ue

comped

tomo

phy

guide

fine

need

aspir

on

>A

has

pro;e

to

safe,

effec

, and


77/127

Negative gram stain

and culture

STERILE NECROSIS: supportive

care, consider repeat FNA every 5–7days if clinically indicated

Continue antibiotics and obsedelayed minimally invasive su

endoscopic, or radiologic debridif asymptomatic: consider no debr

@igure 1'

Management

of pancreatic

necrosis

(hen

infection is

suspected0

7nfected

necrosis

should be

considered in

patients (ith

pancreatic or

eFtrapancreat

ic necrosis

(ho

deteriorate or

fail to

impro;e after

A4 for

Gram stain

and culture to

guide use of

appropriate

antibiotics or

3ii4 empiric

use of

antibiotics

(ithout CT

>A should

be gi;en0 7n

patients (ith

infectednecrosis,

antibiotics

no(n to

penetrate

pancreatic

necrosis may

be useful in

delaying

inter;ention,

thus

decreasing

morbidity and

mortality0 7n

stable

patients (ithinfected

necrosis,

surgical,

radiolo

and1o

endos

c drain

should

delaye

by

prefer

* (ee

allo( t

de;elo

ent of

(all

aroun

necro

3(alle

pancr

necro


78/127

accurate in

distinguishing

infected and sterile

necrosis 3/',!' 40

As patients (ith

infected necrosis

and sterilenecrosis may

appear similar (ith

leuocytosis, fe;er,

and organ failure

3!'A

should be

considered (hen

an infection is

suspected0 An

immediate re;ie(

of the Gram stain

(ill often establish

a diagnosis0Ho(e;er, it may

be prudent to

begin antibiotics

(hile a(aiting

microbiologic

confirmation0 7f

culture reports are

negati;e, the

antibiotics can be

discontinued0

?ere is some

contro;ersy as to(hether a CT >A

is neces5sary in all

patients 3 @igure

140 7n many

patients, the CT

>A (ould not

inBuence the

management

3!'-40 7ncreased

use of

conser;ati;e

management and

minimally in;asi;e

drainage ha;e

decreased

use of >A

the diagnosi

infected

necrosis 3

Many patie

(ith sterile

infected

necrosis ei

impro;e Oui

or beco

unstable,

decisions

inter;ention

a minim

in;asi;e ro

(ill not be i

enced by

results of

aspiration0

consensus

conference c

cluded that should only

used in se

situations (h

there is

clinical respo

to antibio

such as (he

fungal infec

is suspec

3/*40

>8T$7T7I>7> AP

Recommend

ons

!0 7n mild AP

oral

feedings

can be

started

immediat

y if there

no nauseand

;omiting,

and the

abdomina

pain has

resol;ed

3condition

l

recomme

dation,

moderate

Ouality ofe;idence

%0 7n mild AP


79/127

initiation of

feeding (ith

a lo(5fat

solid diet

appears as

safe as a

clear liOuid

diet

3conditional

recommen5

dations,

moderate

Ouality of

e;idence40'0 7n se;ere AP,

enteral

nutrition is

recommend

ed to

pre;ent

infectious

complication

s0 Parenteralnutrition

should

be

a;oide

d,

unless

the

enteral

route

is not

a;aila

ble,

not

tolerat

ed, or

not

meetin

g

caloric

reOuir

ement

s

3stron

g

recommenda

tion,

high

Ouality

of

e;iden

ce40

*0 >asogastric

deli;ery

and

naso2e2una

l deli;ery

of

enteral

feeding

appear

compar

able in

eRcacy

and

safety

3strong

recomm

endatio

n,

moderat

e Ouality

of

e;idenc

e40

S8MMA$I=)7D=>C=Nutritin in!ild AP

Historically,

despite

absence

clinical d

patients (ith

(ere ept >

3nothing

mouth4 to rest

pancreas 3

Most guidel

in the

recommended

>PI

resolution of

and so

suggested

a(aiting

normali@ation

pancre5atic

en@ymes or e

imaging e;ide

of resolution

inBam5mation

before resum

oral feed

3/'40 ? e nee

place

pancreas at

until comp

resolution of

no longer

The A!eric"n 8urn"l #


80/127

GAST$I=>T=$IIG)I8M= !+- J S=PT=M#=$ %+!' $$$'"!9g"str'c!


81/127


seems

imperati;e0 ?e

long5 held

assumption that

the in Bamed

pancreas

reOuiresprolonged rest by

fasting does not

appear to be

supported by

laboratory and

clinical

obser;ation

3!'940 Clini5cal

and eFperimental

studies sho(ed

that bo(el rest is

associated (ithintestinal mucosal

atrophy and

increased

infectious compli5

cations because

of bacterial

translocation from

the gut0 Multiple

studies ha;e

sho(n that

patients pro;ided

oral feeding early

in the course of AP ha;e a

shorter hospital

stay, decreased

infec5tious

complications,

decreased

morbidity, and

decreased

mortal5ity

3!!


82/127

controlled clinical

trials in;ol;5ing '-!

patients found a

decrease in

infectious

complications,

organ failure, and

mortality in patients

(ith se;ere AP (ho

(ere pro;ided

enteral nutrition as

compared (ith total

parenteral nutri5tion

3!*'40 Although

further study is

needed, continuous

infusion is preferred

o;er cyclic or bolus

administration0

Although the use

of a naso2e2unal

route has been

traditionallypreferred to a;oid

the gastric phase of

stimulation,

nasogastric enteral

nutrition appears as

safe0 A systematic

re;ie( describ5ing

9% patients from *

studies on

nasogastric tube

feeding found that

nasogastric feeding(as safe and (ell

tolerated in patients

(ith predicted

se;ere AP 3!!aso2e2

tube placem

reOuires

inter;entional

radiology

endoscopy and

can be eFpens

or these reas

nasogastric

feeding should

preferred 3!*<

large multice

trial sponsored

the >ational 7

tutes of He

3>7H4 is curre

being performe

in;estigate (he

nasogastric

naso2e2unal

feedings

preferred in thes


83/127

patients because

of signi6cant

eFperimental and

some human

e;idence of

superiority of

distal 2e2unal

feeding in AP0

TH= $I= IS8$G=$ 7> AP

Recommendatio

ns

!0 7n patients

(ith mild

AP, foundto ha;e

gallstones

in the

gallbladder,

a

cholecyste

ctomy

should be

performed

before

discharge

to pre;ent

a

recurrence

of AP

3moderate

recommen

dation,

moderate

Ouality of

e;idence40

%0 7n a patient

(ith

necroti@ing

biliary AP, inorder to

pre;ent

infection,

cholecystect

omy is to be

deferred

until acti;e

inBammatio

n subsides

and Buid

collections

resol;e orstabili@e

3strong

recommend

ation,

moderate

e;idence40

'0

Asymptom

ic

pseudocys

and

pancreatic

and1or eFt

pancreatic

necrosis d

not (arran

inter;entio

regardless

of si@e,

location,

and1or

eFtension

3moderate

recommen

ation, highOuality of

e;idence4

*0 7n stable

patients

(ith

infected

necrosis,

surgical,

radiologic,

and1or

endoscopi

drainage

should be

delayed

preferably

for more

than *

(ees to

allo( liOue

cation of th

contents

and the

de;elopme

t of a 6brou

(all arounthe necros

3(alled5oE

necrosis4

3strong

recommen

ation, lo(

Ouality of

e;idence4/0 7n symptomat

patients (ith

infected

necrosis,minimally

in;asi;e


84/127

methods of

necrosectomy

are preferred to

open necro5

sectomy 3strong

recommendatio

n, lo( Ouality of

e;idence40

S8MMA$ I=)7D=>C=Chlec+stect!+

7n patients (ith

mild gallstone

pancreatitis,

cholecystectomy

should be

performed during

the indeF

hospitali@ation0 ?e

cur5rent literature,

(hich includes -

cohort studies and

one rando5mi@ed

trial describing 99-

patients (ho had

and (ho had not

undergone

cholecystectomy

for biliary

pancreatitis, 9/

3!-K4 (ere

readmitted for

recurrent biliary

e;ents (ithin 9+

days of discharge

3+K ;s0 !-K, P L

+0+++!4, including

recurrent biliary

pancreatitis 3 n W

*', -K4 3!*-40

Some of the cases

(ere found to be

se;ere0 #ased on

this eFperience,there is a need for

early

cholecystectomy

during the same

hospitali@ation,

the attac is m

Patients (ho h

se;ere

especially

pancre5atic

necrosis,

reOuire com

decision ma

bet(een

surgeon

gastroenterolog

7n these patie

cholecystec5tom

is typically dela

until 3i4 a later t

in the typic

prolonged

hospitali@ation,

as part of

management

the pancre

necrosis if presor 3iii4 a

discharge

3!*-,!*940 =a

guidelines

recommended

cholecystectom

Ker % attacs

7AP, (ith

presumption

many such ca

might be beca

of microlithiaHo(e;er,

population5bas

study found

cholecystectom

performed

recurrent atta

of AP (ith

stones1sludge

ultrasound and

signi6cant

ele;ation of

tests during

attac of AP

associated (it

/+K recurre

of AP 3!/+40




85/127

/ Tenner et al.

7n the

a2ority

tients

h

llston

ncrea

s, the

mmon

e duct

one

sses

the

oden

m0

outine

$CP is

t

propri

e

less

ere is

high

spicio

of a

rsis5

nt

mmon

e duct

one,anifest

by an

e;atio

n the

rubin

/!40

tients

h

d AP,

h

rmal

rubin,n

dergo

prosco

c

olecy

ectom

(ith

raope

i;e

olangi

raphy,

d any

mainin

bile

duct

stones

can be

dealt

(ith by

postoper

ati;e or

intraope

rati;e

=$CP0

7n

patients

(ith lo(

to

moderat

e ris,

M$CP

or =8S

can be

used

preoper

ati;ely,but

routine

use of

M$CP

is

unneces

sary0 7n

patients

(ith mild

AP (ho

cannot

undergosurgery,

such as

the frail

elderly

and1or

those

(ith

se;ere

comorbi

d

disease,

biliarysphincte

rotomy

alone

may be

an

eEecti;e

(ay to

reduce

further

attacs

of AP,

although

attacs

of


86/127

olecy

tis

ay still

cur

'40

=#$7=M=T I

=C$S7Sstoric

y,

en

crose

omy1d

ridem

t (as

e

atme

of

oice

r

ected

crosi

and

mpto

atic

erile

crosi

ecade

ago,

tients

therile

crosi

der(

t

rly

bri5

ment

at

sulted

creas

ortalit

or

s

ason,

rly

en

bride

ent

r

erile

crosi

(asando

d

3'%40

Ho(5

e;er,

debride

ment for

sterile

necrosi

s is

recomm

ended if

associ5

ated

(ith

gastric

outlet

obstruct

ion

and1or

bile

duct

obstruct

ion0 7n

patient

Documents

Guideline Pancreatite 2013 AJG