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Acute Pancreatitis

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General Information

Description

  • acute, inflammatory process of the pancreas which can affect multiple organ systems3

Definitions

  • disease onset defined as time of onset of abdominal pain2
  • chronic pancreatitis defined as progressive inflammation of pancreas with destruction of pancreatic secretory cells leading to malnutrition and diabetes

Types

Revised Atlanta criteria

  • mild acute pancreatitis defined as both1,2
    • absence of organ failure
    • absence of local or systemic complications, such as pancreatic necrosis
  • moderately severe acute pancreatitis characterized by presence of either1,2
    • transient organ failure (organ failure resolving in ≤ 48 hours)
    • local or systemic complications without persistent organ failure
  • severe acute pancreatitis (about 15%-20%)1,2
    • defined as persistence of organ failure (single or multiple) for > 48 hours
    • in first 48 hours, cannot distinguish between severe disease which is temporary or severe acute pancreatitis which is developing
    • organ failure defined as Marshall score > 2 and must be recorded ≥ once during each of 3 consecutive days in any of following systems
      • respiratory system (partial pressure of oxygen to fraction of inspired oxygen ratio [PO2 /FIO2])
        • score 0 if > 400
        • score 2 if 301-400
        • score 3 if 201-300
        • score 4 if 101-200
      • cardiovascular system (systolic blood pressure)
        • score 0 if > 90 mm Hg
        • score 1 if < 90 mm Hg and fluid responsive
        • score 2 if < 90 mm Hg and not fluid responsive
        • score 3 if < 90 mm Hg and pH < 7.3
        • score 4 if < 90 mm Hg and pH < 7.2
      • renal system (serum creatinine levels by micromol/L or mg/dL)
        • score 0 if < 134 or < 1.4
        • score 1 if 134-169 or 1.4-1.8
        • score 2 if 170-310 or 1.9-3.6
        • score 3 if 311-439 or 3.6-4.9
        • score 4 if > 439 or > 4.9
    • multisystem organ failure defined as ≥ 2 organs failing over the same 2- to 3-day period

Morphologic (image-based) classification

  • interstitial edematous pancreatitis (IEP)2
    • diffuse or localized enlargement of the pancreas
    • normal, homogeneous enhancement of pancreatic parenchyma
    • peripancreatic fat usually shows some inflammatory changes of haziness or mild stranding
    • usually resolve within first week
  • necrotizing pancreatitis2
    • presence of necrosis involving both the pancreas and peripancreatic tissues (most common)
    • necrosis of only the peripancreatic tissue (less common, worse prognosis compared with patients with IEP)
    • necrosis of only pancreatic parenchyma (rare)
    • necrosis may be
      • sterile
      • infected
        • rare in first week
        • no absolute correlation between extent of necrosis and risk of infection and duration of symptoms
        • infection presumed if extraluminal gas present in nonenhancing area(s) on contrast-enhanced computed tomography (CECT) (virtually pathognomonic for presence of gas-forming organism without or with perforation)
        • diagnosis based definitively only on image-guided, fine-needle aspiration (FNA) with positive Gram stain and culture
        • may evolve from solid necrosis early in course to variable liquefaction and variable reabsorption
        • if not completely reabsorbed, may persist as area of walled-off pancreatic necrosis (WOPN) which may be
          • symptomatic
          • cause of pain or mechanical obstruction of duodenum and/or bile duct

References

General references used

  1. Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400-15OpenInNewPDFPictureAsPdf
  2. Banks PA, Bollen TL, Dervenis C, et al; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102-11OpenInNew
  3. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008 Jan 12;371(9607):143-52OpenInNew, commentary can be found in Lancet 2008 Mar 29;371(9618):1072OpenInNew
  4. American Gastroenterological Association (AGA) Institute on "Management of Acute Pancreatitis" Clinical Practice and Economics Committee, AGA Institute Governing Board. AGA Institute medical position statement on acute pancreatitis. Gastroenterology. 2007 May;132(5):2019-21OpenInNew, supporting literature review in Gastroenterology 2007 May;132(5):2022OpenInNew

Recommendation grading systems used

  • Endocrine Society uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
    • strength of recommendation
      • Strong recommendation - guideline panel members have high confidence that desirable effects of recommendation outweigh undesirable effects (or vice versa)
      • Weak recommendation - guideline panel members conclude with less confidence that desirable effects of recommendation probably outweigh undesirable effects, or benefits and harms are finely balanced, or appreciable uncertainty
    • quality of evidence
      • High-quality evidence - consistent evidence from well-performed randomized controlled trials, or exceptionally strong evidence from unbiased observational studies
      • Moderate-quality evidence - randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise evidence), or unusually strong evidence from unbiased observational studies
      • Low-quality evidence - ≥ 1 critical outcome from observational studies, randomized controlled trials with serious flaws, or indirect evidence
      • Very low-quality evidence - ≥ 1 of the critical outcomes from unsystematic clinical observations or very indirect evidence
  • American College of Gastroenterology (ACG) uses Grading of Recommendations Assessment, Development and Evaluation (GRADE) system
    • strength of recommendation
      • Strong recommendation - high quality evidence to support a recommendation for or against use and/or benefits of use clearly outweigh adverse effects
      • Conditional (weak) recommendation - low quality evidence to support a recommendation for or against use and/or benefits of use do not clearly outweigh adverse effects
    • quality of evidence
      • High-quality evidence - further research very unlikely to change confidence in estimate of effect
      • Moderate-quality evidence - further research likely to have important impact on confidence in estimate of effect and may change estimate
      • Low-quality evidence - further research very likely to have important impact on confidence in estimate of effect and is likely to change estimate
      • Very low-quality evidence - any estimate of effect is very uncertain
    • Reference - ACG guideline on management of acute pancreatitis (mnh23896955pmdc23896955pAm J Gastroenterol 2013 Sep;108(9):1400OpenInNewPDFPictureAsPdf)
  • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline grading system
    • grades of recommendation
      • Grade A - based on high level (Level I or II), well-performed studies with uniform interpretation and conclusions by expert panels
      • Grade B - based on high level, well-performed studies with varying interpretations and conclusions by expert panels
      • Grade C - based on lower level evidence (Level II or less) with inconsistent findings and/or varying interpretations or conclusions by expert panels
    • levels of evidence
      • Level I - evidence from properly conducted randomized, controlled trials
      • Level II - evidence from controlled trials without randomization, cohort or case-control studies, multiple time series, or dramatic uncontrolled experiments
      • Level III - descriptive case series, or opinions of expert panels
    • Reference - SAGES guideline on clinical application of laparoscopic biliary tract surgery (20706739Surg Endosc 2010 Oct;24(10):2368OpenInNew)
  • Infectious Disease Society of America (IDSA) strength of recommendation and quality evidence grades
    • strength of recommendations
      • Grade A - good evidence to support a recommendation for or against use
      • Grade B - moderate evidence to support a recommendation for or against use
      • Grade C - poor evidence to support a recommendation
    • quality of evidence
      • Level I - evidence from > 1 properly randomized, controlled trial
      • Level II - evidence from > 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from > 1 center); from multiple time series; or from dramatic results from uncontrolled experiments
      • Level III - evidence from opinions of authorities, based on clinical experience, descriptive studies, or reports of expert committees
  • American Society for Apheresis (ASFA) recommendation grading system
    • categories of indications for therapeutic apheresis
      • Category I - disorders for which apheresis is accepted as first-line therapy, either as primary stand-alone treatment or in conjunction with other modes of treatment
      • Category II - disorders for which apheresis is accepted as second-line therapy, either as stand-alone treatment or in conjunction with other modes of treatment
      • Category III - optimum role of apheresis therapy is not established and decision-making should be individualized
      • Category IV - disorders in which published evidence demonstrates or suggests apheresis to be ineffective or harmful; Institutional Review Board (IRB) approval is desirable if apheresis treatment is undertaken in these circumstances
    • grades of recommendations
      • Grade 1A - strong recommendation, high-quality evidence
        • can apply to most patients in most circumstances without reservation
        • supported by randomized controlled trials (RCTs) without important limitations or overwhelming evidence from observational studies
      • Grade 1B - strong recommendation, moderate-quality evidence
        • can apply to most patients in most circumstances without reservation
        • supported by RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies
      • Grade 1C - strong recommendation, low- or very low-quality evidence
        • recommendation may change when higher quality evidence becomes available
        • supported by observational studies or case series
      • Grade 2A - weak recommendation, high-quality evidence
        • best action may differ depending on circumstances of patients' or societal values
        • supported by RCTs without important limitations or overwhelming evidence from observational studies
      • Grade 2B - weak recommendation, moderate-quality evidence
        • best action may differ depending on circumstances of patients' or societal values
        • supported by RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies
      • Grade 2C - weak recommendation, low- or very low-quality evidence
        • very weak recommendation; other alternatives may be equally reasonable
        • supported by observational studies or case series
    • Reference - ASFA guideline on use of therapeutic apheresis in clinical practice (27322218J Clin Apher 2016 Jun;31(3):149OpenInNew)
  • European Association for the Study of the Liver (EASL) grading of recommendations
    • strength of recommendations
      • Strong recommendation - most or all individuals in relevant population will benefit by following recommendation; there is certainty about various factors including aggregate evidence quality and assessment of anticipated benefits and harms
      • Weak recommendation - there is uncertainty about various factors including aggregate evidence quality and assessment of anticipated benefits and harms
    • quality of evidence grades
      • High-quality evidence - further research very unlikely to change confidence in estimate of effect; randomized trials or double-upgraded observational studies
      • Moderate-quality evidence - further research likely to have important impact on confidence in estimate of effect and may change estimate; downgraded randomized trials or upgraded observational studies
      • Low-quality evidence - further research very likely to have important impact on confidence in estimate of effect and likely to change estimate; observational studies or double-downgraded randomized trials
      • Very low-quality evidence - estimate is very uncertain; case series/case reports, downgraded observational studies, triple-downgraded randomized trials
    • Reference - EASL clinical practice guideline on prevention, diagnosis, and treatment of gallstones (27085810J Hepatol 2016 Jul;65(1):146OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T127664, Acute Pancreatitis; [updated 2018 Dec 04, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T127664. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Definitions

    • KeyboardArrowRight

      Types

      • Revised Atlanta criteria

      • Morphologic (image-based) classification

  • KeyboardArrowRight

    Epidemiology

    • Incidence/Prevalence

    • Likely risk factors

    • Factors not associated with increased risk

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • Lungs

      • Abdomen

      • Neuro

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • KeyboardArrowRight

      Blood tests

      • Pancreatic-specific tests

      • Differentiating alcoholic from biliary pancreatitis

      • Serum triglyceride levels

      • Liver function tests in gallstone pancreatitis

      • Tests for severity

    • Urine studies

    • KeyboardArrowRight

      Imaging studies

      • KeyboardArrowRight

        Imaging options

        • Abdominal ultrasound

        • X-ray

        • Contrast-enhanced computed tomography (CECT)

        • Magnetic resonance imaging (MRI)

        • Endoscopic ultrasound

        • Endoscopic retrograde cholangiopancreatography (ERCP)

        • Magnetic resonance cholangiopancreatography (MRCP)

      • Image-based classification of pancreatic local complications

    • KeyboardArrowRight

      Other diagnostic testing

      • Testing for atypical causes of acute pancreatitis

      • Severity classification in pediatric patients

      • CT-guided fine-needle aspiration

      • Detection of ampullary obstruction

  • KeyboardArrowRight

    Management

    • Management overview

    • Treatment setting

    • Fluid and electrolytes

    • KeyboardArrowRight

      Diet

      • Recommendations for nutrition support

      • Enteral nutrition support

      • Enteral vs. parenteral nutrition

    • KeyboardArrowRight

      Medications

      • Pain relief

      • KeyboardArrowRight

        Antibiotics

        • Prophylactic antibiotics

        • Antibiotics for infected necrosis

        • Antibiotics for extrapancreatic infections

      • Protease inhibitors

      • Insulin

      • Probiotics

      • Other medications

    • KeyboardArrowRight

      Surgery and procedures

      • Endoscopic retrograde cholangiopancreatography (ERCP)

      • Management of pancreatic fluid collections and pseudocyst

      • KeyboardArrowRight

        Management of necrosis

        • Indication and timing for intervention

        • Method of intervention

      • Cholecystectomy

      • Peritoneal lavage

    • Consultation and referral

    • KeyboardArrowRight

      Other management

      • Nasogastric suction

      • Treatment of acute hypertriglyceridemic pancreatitis

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • General prognosis

      • Prognostic scoring systems

      • Other prognostic factors

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

  • KeyboardArrowRight

    Quality Improvement

    • Choosing Wisely

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

      • Asian guidelines

      • Mexican guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Alejandro Piscoya MD, MSc(Ed)
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Affiliations

Professor of Gastroenterology, Universidad Peruana de Ciencias Aplicadas; Lima, Peru

Conflicts of Interest

Dr. Piscoya declares no relevant financial conflicts of interest.

Recommendations Editor
Amir Qaseem MD, PhD, MHA, FACP
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Affiliations

Vice President of Clinical Policy, American College of Physicians; Pennsylvania, United States; President Emeritus, Guidelines International Network; Germany

Conflicts of Interest

Dr. Qaseem declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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CT of acute pancreatitis

CT of acute pancreatitis

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