(613610363) ACG Guideline AcutePancreatitis September 2013

8/18/2019 (613610363) ACG Guideline AcutePancreatitis September 2013

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The American Journal of GASTR OE NTER OLOGY© 2013 by the American College o Ga!troenterologyThe American Journal of GASTR OENTER OLOGY ww w.amjgastro.com

nat"re #"bli!hing gro"# PRACTICE GUIDELIE! "

American College o Ga!troenterology G"i$eline%

&anagement o Ac"te 'ancreatiti!Scott Tenner( &)( &'*( +ACG1( ,ohn -aillie( &-( Ch-( +RC'( +ACG2( ,ohn )e.itt( &)( +ACG3 an$ Santhi S/aroo# ege( &)( +ACG

This gui#eline $resents recommen#ations for the management of $atients with acute $ancreatitis %AP&. During

the $ast #eca#e' there ha(e )een new un#erstan#ings an# #e(elo$ments in the #iagnosis' etiolog*' an# earl*

an# late management of the #isease. As the #iagnosis of AP is most often esta)lishe# )* clinical s*m$toms an#

la)orator* testing' contrast+enhance# com$ute# tomogra$h* %CECT& an#,or magnetic resonance imaging %-RI& of

the $ancreas shoul# )e reser(e# for $atients in whom the #iagnosis is unclear or who fail to im$ro(e clinicall*.

emo#*namic status shoul# )e assesse# imme#iatel* u$on $resentation an# resuscitati(e measures )egun

as nee#e#. Patients with organ failure an#,or the s*stemic inflammator* res$onse s*n#rome %!IR!& shoul# )e

a#mitte# to an intensi(e care unit or interme#iar* care setting whene(er $ossi)le. Aggressi(e h*#ration shoul# )e

$ro(i#e# to all $atients' unless car#io(ascular an#,or renal comor)i#ites $reclu#e it. Earl* aggressi(e intra(enoush*#ration is most )eneficial within the first "/ 0 /1 h' an# ma* ha(e little )enefit )e*on#. Patients with AP an#

concurrent acute cholangitis shoul# un#ergo en#osco$ic retrogra#e cholangio$ancreatogra$h* %ERCP& within /1 h

of a#mission. Pancreatic #uct stents an#,or $ost$roce#ure rectal nonsteroi#al anti+inflammator* #rug %!AID&

su$$ositories shoul# )e utili2e# to lower the ris3 of se(ere $ost+ERCP $ancreatitis in high+ris3 $atients. Routine use

of $ro$h*lactic anti)iotics in $atients with se(ere AP an#,or sterile necrosis is not recommen#e#. In $atients with

infecte# necrosis' anti)iotics 3nown to $enetrate $ancreatic necrosis ma* )e useful in #ela*ing inter(ention' thus

#ecreasing mor)i#it* an# mortalit*. In mil# AP' oral fee#ings can )e starte# imme#iatel* if there is no nausea an#

(omiting. In se(ere AP' enteral nutrition is recommen#e# to $re(ent infectious com$lications' whereas $arenteral

nutrition shoul# )e a(oi#e#. As*m$tomatic $ancreatic an#,or e4tra$ancreatic necrosis an#,or $seu#oc*sts #o not

warrant inter(ention regar#less of si2e' location' an#,or e4tension. In sta)le $atients with infecte# necrosis' surgical'

ra#iologic' an#,or en#osco$ic #rainage shoul# )e #ela*e#' $refera)l* for 1 wee3s' to allow the #e(elo$ment of a wall

aroun# the necrosis.

Am J Gastroenterol a$ance online #"blication( 30 ,"ly 2013 $oi%10410356a7g420134215

Ac"te #ancreatiti! 8A'9 i! one o the mo!t common $i!ea!e!

o the ga!trointe!tinal tract( lea$ing to tremen$o"! emotion:

al( #hy!ical( an$ inancial h"man b"r$en 81(294 ;n the 94 T/o $i!tinct #ha!e! o A' hae no/ been

i$entiie$% 8i9 early 8/ithin 1 /eeB9( characterie$ by the

!y!temic inlam: matory re!#on!e !yn$rome 8S;RS9 an$6or

organ ail"re an$ 8ii9 late 8 1 /eeB9( characterie$ by localcom#lication!4 ;t i! critical to recognie the #aramo"nt

im#ortance o organ ail"re in $etermining $i!ea!e !eerity4

Local com#lication! are $eine$ a! #eri#ancreatic l"i$

collection!( #ancreatic an$ #er i #ancr eatic necro!i! 8!terile or

inecte$9( #!e"$ocy!t!( an$ /alle$:o necr o: !i! 8!terile or

inecte$94 ;!olate$ eDtra#ancreatic necro!i! i! al!o incl"$e$

"n$er the term necrotiing #ancreatiti! altho"gh

1State


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2 Tenner et al. -anagement of Acute Pancreatitis 2

8iii9 characteri!tic in$ing! rom ab$ominal imaging 8!tr ong

recommen$ation( mo$erate F"ality o ei$ence94

24 Contra!t:enhance$ com#"te$ tomogra#hy 8CECT9 an$6or

magnetic re!onance imaging 8&R;9 o the #ancrea! !ho"l$

be re!ere$ or #atient! in /hom the $iagno!i! i! "nclear

or /ho ail to im#roe clinically /ithin the ir!t 5 ?2 h

ater ho!#ital a$mi!!ion or to eal"ate com#lication!

8!tr ong recommen$ation( lo/ F"ality o ei$ence94

o"tcome! liBe #er!i!tent organ ail"re( inecte$ necro!i!( an$

mor : tality o thi! entity are more oten !een /hen com#are$ to

inter : !titial #ancreatiti!( the!e com#lication! are more

commonly !een in #atient! /ith #ancreatic #arenchymal necro!i!

8?94 There i! no/ a thir$ interme$iate gra$e o !eerity(

mo$erately !eere A'( that i! characterie$ by localcom#lication! in the ab!ence o #er !i!tent organ ail"re4 'atient!

/ith mo$erately !eere A' may hae tran: !ient organ ail"re(

la!ting H 5 h4 &o$erately !eere A' may al!o eDacerbate

"n$erlying comorbi$ $i!ea!e b"t i! a!!ociate$ /ith a lo/

mortality4 Seere A' i! no/ $eine$ entirely on the #re!ence o

#er!i!tent organ ail"re 8$eine$ by a mo$iie$ &ar!hall Score9

8594 .e ir!t $i!c"!! the $iagno!i!( etiology( an$ !eerity o A'4

.e then oc"! on the early me$ical management o A' ollo/e$

by a $i!c"!!ion o the management o com#licate$ $i!ea!e( mo!t

nota: bly #ancreatic necro!i!4 Early management oc"!e! on

a$ance: ment! in o"r "n$er!tan$ing o aggre!!ie intraeno"!

hy$ration( /hich /hen a##lie$ early a##ear! to $ecrea!e

morbi$ity an$ mortality 8=(1094 The eoling i!!"e! o

antibiotic!( n"trition( an$ en$o!co#ic( ra$iologic( !"rgical( an$

other minimally ina!ie

interention! /ill be a$$re!!e$4

A !earch o &E)L;NE ia the O;) interace "!ing the

&eS* term Iac"te #ancreatiti!J limite$ to clinical trial!(

reie/!( g"i$e: line!( an$ meta:analy!i! or the year! 1=>>2012

/a! "n$er taB en /itho"t lang"age re!triction( a! /ell a! a

reie/ o clinical trial! an$ reie/! Bno/n to the a"thor! /ere

#erorme$ or the #r e#ara: tion o thi! $oc"ment4 The GRA)E

!y!tem /a! "!e$ to gra$e the !trength o recommen$ation! an$

the F"ality o ei$ence 81194 An eD#lanation o the F"ality o

ei$ence an$ !trength o the r ecom: men$ation! i! !ho/n inTa)le "4 Each !ection o the $oc"ment #re!ent! the Bey

recommen$ation! relate$ to the !ection to#ic( ollo/e$ by a

!"mmary o the !"##orting ei$ence4 A !"mmary o

recommen$ation! i! #roi$e$ in Ta)le /4

);AGNOS;S

Recommendations

14 The $iagno!i! o A' i! mo!t oten e!tabli!he$ by the

#r e!ence o 2 o the 3 ollo/ing criteria% 8i9 ab$ominal #ain

con!i!tent /ith the $i!ea!e( 8ii9 !er"m amyla!e an$6or

li#a!e greater than three time! the "##er limit o normal(

an$6or

);AGNOS;S% CL;N;CAL

'RESENTAT;ON

'atient! /ith A' ty#ically #re!ent /ith e#iga!tric or let " ##er

F"a$rant #ain4 The #ain i! "!"ally $e!cribe$ a! con!tant /ith

ra$iation to the bacB( che!t( or lanB!( b"t thi! $e!cri#tion i! non:

!#eciic4 The inten!ity o the #ain i! "!"ally !eere( b"t can be

ari: able4 The inten!ity an$ location o the #ain $o not

correlate /ith !eerity4 'ain $e!cribe$ a! $"ll( colicBy( or

locate$ in the lo/er ab$ominal region i! not con!i!tent /ith A'

an$ !"gge!t! an alter : natie etiology4 Ab$ominal imaging may be hel#"l to $eter mine the $iagno!i! o A' in #atient! /ith

aty#ical #r e!entation!4

);AGNOS;S% LA-ORATORY

'ARA&ETERS

-eca"!e o limitation! in !en!itiity( !#eciicity( an$ #o!itie

an$ negatie #re$ictie al"e( !er"m amyla!e alone cannot be

"!e$ reliably or the $iagno!i! o A' an$ !er"m li#a!e i!

#r e er r e$4 Ser"m amyla!e in A' #atient! generally ri!e! /ithin a

e/ ho"r ! ater the on!et o !ym#tom! an$ ret"rn! to normal

al"e! /ithin

3@ $ay! ho/eer( it may remain /ithin the normal range ona$mi!!ion in a! many a! one:ith o #atient! 812(1394 Com#ar e$

/ith li#a!e( !er"m amyla!e ret"rn! more F"icBly to al"e! belo/

the "##er limit o normal4 Ser"m amyla!e concentration! may

be normal in alcohol:in$"ce$ A' an$ hy#ertriglyceri$emia4

Ser"m amyla!e concentration! might be high in the ab!ence

o A' in macroamyla!aemia 8a !yn$rome characterie$ by

the ormation o large molec"lar com#leDe! bet/een amyla!e

an$ abnormal imm"noglob"lin!9( in #atient! /ith $ecrea!e$

glomer"lar iltration rate( in $i!ea!e! o the !aliary glan$!(

an$ in eDtra#ancreatic ab$ominal $i!ea!e! a!!ociate$ /ith

inlammation( incl"$ing ac"te a##en$iciti!( cholecy!titi!( inte!:

tinal ob!tr"ction or i!chemia( #e#tic "lcer( an$ gynecological$i!ea!e!4

Ser"m li#a!e a##ear! to be more !#eciic an$ remain! ele:

ate$ longer than amyla!e ater $i!ea!e #re!entation4 )e!#ite

recommen$ation! o #reio"! ine!tigator! 819 an$ g"i$eline!

or the management o A' 81@9 that em#ha!ie the a$antage

o !er"m li#a!e( !imilar #roblem! /ith the #re$ictie al"e

remain in certain #atient #o#"lation!( incl"$ing the eDi!tence

o macroli#a!emia4 Li#a!e i! al!o o"n$ to be eleate$ in a ari:

ety o non#ancreatic $i!ea!e!( !"ch a! renal $i!ea!e( a ##en:

$iciti!( cholecy!titi!( an$ !o on4 ;n a$$ition( an "##er limit o

normal greater than 3@ time! may be nee$e$ in $iabetic! /ho

a##ear to hae higher me$ian li#a!e com#are$ /ith non$ia betic

Ta)le ". GRADE s*stem of :ualit* of e(i#ence an# strength of

recommen#ation

*igh +"rther re!earch i! ery "nliBely to change o"r coni$ence inthe e!timate o eect4

&o$erate +"rther re!earch i! liBely to hae an im#ortant im#act ono"r coni$ence in the e!timate o eect an$ may change thee!timate4

Lo/ +"rther re!earch i! ery liBely to hae an im#ortant im#act ono"r coni$ence in the e!timate o eect an$ i! liBely to changethe e!timate4

ery lo/ Any e!timate o the eect i! ery "ncertain4


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3 Tenner et al. -anagement of Acute Pancreatitis 3#atient! or "nclear rea!on! 81>(1?94 A ,a#ane!e con!en!"! con:

erence to $etermine a##ro#riate Ic"to J al"e! or amyla!e an$

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Ta)le /. !ummar* of recommen#ations

)iagno!i!

14 The $iagno!i! o A' i! mo!t oten e!tabli!he$ by the #re!ence o t/o o the three ollo/ing criteria% 8i9 ab$ominal #ain con!i!tent /ith the $i!ea!e(8ii9 !er"m amyla!e an$6or li#a!e greater than three time! the "##er limit o normal( an$6or 8iii9 characteri!tic in$ing! rom ab$ominal imaging

8!trong recommen$ation( mo$erate F"ality o ei$ence94

24 Contra!t:enhance$ com#"te$ tomogra#hic 8CECT9 an$6or magnetic re!onance imaging 8&R;9 o the #ancrea! !ho"l$ be re!ere$ or #atient! in/hom the $iagno!i! i! "nclear or /ho ail to im#roe clinically /ithin the ir!t 5?2 h ater ho!#ital a$mi!!ion 8!trong recommen$ation( lo/ F"ality o ei$ence94

Etiology

34 Tran!ab$ominal "ltra!o"n$ !ho"l$ be #erorme$ in all #atient! /ith ac"te #ancreatiti! 8!trong recommen$ation( lo/ F"ality o ei$ence94

4 ;n the ab!ence o gall!tone! an$6or hi!tory o !igniicant hi!tory o alcohol "!e( a !er"m triglyceri$e !ho"l$ be obtaine$ an$ con!i$ere$ the etiologyi 1(000 mg6$l 8con$itional recommen$ation( mo$erate F"ality o ei$ence94

@4 ;n a #atient ol$er than 0 year!( a #ancreatic t"mor !ho"l$ be con!i$ere$ a! a #o!!ible ca"!e o ac"te #ancreatiti! 8con$itional recommen$ation(

lo/ F"ality o ei$ence94

>4 En$o!co#ic ine!tigation in #atient! /ith ac"te i$io#athic #ancreatiti! !ho"l$ be limite$( a! the ri!B! an$ beneit! o ine!tigation in the!e #atient! are

"nclear 8con$itional recommen$ation( lo/ F"ality o ei$ence94

?4 'atient! /ith i$io#athic #ancreatiti! !ho"l$ be reerre$ to center! o eD#erti!e 8con$itional recommen$ation( lo/ F"ality o ei$ence94

54 Genetic te!ting may be con!i$ere$ in yo"ng #atient! 8 H 30 year! ol$9 i no ca"!e i! ei$ent an$ a amily hi!tory o #ancreatic $i!ea!e i! #re!ent

8con$itional recommen$ation( lo/ F"ality o ei$ence94

;nitial a!!e!!ment an$ ri!B !tratiication

=4 *emo$ynamic !tat"! !ho"l$ be a!!e!!e$ imme$iately "#on #re!entation an$ re!"!citatie mea!"re! beg"n a! nee$e$ 8!trong recommen$ation(mo$erate F"ality o ei$ence94

104 Ri!B a!!e!!ment !ho"l$ be #erorme$ to !tratiy #atient! into higher: an$ lo/er:ri!B categorie! to a!!i!t triage( !"ch a! a$mi!!ion to an inten!ie care!etting 8con$itional recommen$ation( mo$erate F"ality o ei$ence94

114 'atient! /ith organ ail"re !ho"l$ be a$mitte$ to an inten!ie care "nit or interme$iary care !etting /heneer #o!!ible 8!trong recommen$ation(lo/ F"ality o ei$ence94

;nitial management

124 Aggre!!ie hy$ration( $eine$ a! 2@0:@00 ml #er ho"r o i!otonic cry!talloi$ !ol"tion !ho"l$ be #roi$e$ to all #atient!( "nle!! car$ioa!c"lar an$6or renal comorbi$ite! eDi!t4 Early aggre!!ie intraeno"! hy$ration i! mo!t beneicial the ir!t 122 h( an$ may hae little beneit beyon$


134 ;n a #atient /ith !eere ol"me $e#letion( manie!t a! hy#oten!ion an$ tachycar$ia( more ra#i$ re#letion 8bol"!9 may be nee$e$ 8con$itionalrecommen$ation( mo$erate F"ality o ei$ence94

14 Lactate$ Ringer M! !ol"tion may be the #reerre$ i!otonic cry!talloi$ re#lacement l"i$ 8con$itional recommen$ation( mo$erate F"ality o ei$ence94

1@4 +l"i$ reF"irement! !ho"l$ be rea!!e!!e$ at reF"ent interal! /ithin > h o a$mi!!ion an$ or the neDt 25 h4 The goal o aggre!!ie hy$ration!ho"l$ be to $ecrea!e the bloo$ "rea nitrogen 8!trong recommen$ation( mo$erate F"ality o ei$ence94

ERC' in ac"te #ancreatiti!

1>4 'atient! /ith ac"te #ancreatiti! an$ conc"rrent ac"te cholangiti! !ho"l$ "n$ergo ERC' /ithin 2 h o a$mi!!ion 8!trong recommen$ation( mo$erateF"ality o ei$ence94

1?4 ERC' i! not nee$e$ in mo!t #atient! /ith gall!tone #ancreatiti! /ho lacB laboratory or clinical ei$ence o ongoing biliary ob!tr"ction 8!trongrecommen$ation( lo/ F"ality o ei$ence94

154 ;n the ab!ence o cholangiti! an$6or 7a"n$ice( &RC' or en$o!co#ic "ltra!o"n$ 8E


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Ta)le /. Continue#

24 ;n #atient! /ith inecte$ necro!i!( antibiotic! Bno/n to #enetrate #ancreatic necro!i!( !"ch a! carba#enem!( F"inolone!( an$ metroni$aole( may be "!e"l in $elaying or !ometime! totally aoi$ing interention( th"! $ecrea!ing morbi$ity an$ mortality 8con$itional recommen$ation( lo/ F"ality o ei$ence94

2@4 Ro"tine a$mini!tration o anti"ngal agent! along /ith #ro#hylactic or thera#e"tic antibiotic! i! not recommen$e$ 8con$itional recommen$ation( lo/F"ality o ei$ence94

N"trition in ac"te #ancreatiti!

2>4 ;n mil$ A'( oral ee$ing! can be !tarte$ imme$iately i there i! no na"!ea an$ omiting( an$ ab$ominal #ain ha! re!ole$ 8con$itional recommen$a:tion( mo$erate F"ality o ei$ence94

2?4 ;n mil$ A'( initiation o ee$ing /ith a lo/:at !oli$ $iet a##ear! a! !ae a! a clear liF"i$ $iet 8con$itional recommen$ation!( mo$erate F"alityo ei$ence94

254 ;n !eere A'( enteral n"trition i! recommen$e$ to #reent inectio"! com#lication!4 'arenteral n"trition !ho"l$ be aoi$e$ "nle!! the enteral ro"te i!not aailable( not tolerate$( or not meeting caloric reF"irement! 8!trong recommen$ation( high F"ality o ei$ence94

2=4 Na!oga!tric $eliery an$ na!o7e7"nal $eliery o enteral ee$ing a##ear com#arable in eicacy an$ !aety 8!trong recommen$ation( mo$erate F"alityo ei$ence94

The role o !"rgery in ac"te #ancreatiti!

304 ;n #atient! /ith mil$ A'( o"n$ to hae gall!tone! in the gallbla$$er( a cholecy!tectomy !ho"l$ be #erorme$ beore $i!charge to #reent a rec"rrence

o A' 8!trong recommen$ation( mo$erate F"ality o ei$ence94

314 ;n a #atient /ith necrotiing biliary A'( in or$er to #reent inection( cholecy!tectomy i! to be $eerre$ "ntil actie inlammation !"b!i$e! an$ l"i$

collection! re!ole or !tabilie 8!trong recommen$ation( mo$erate F"ality o ei$ence94

324 The #re!ence o a!ym#tomatic #!e"$ocy!t! an$ #ancreatic an$6or eDtra#ancreatic necro!i! $o not /arrant interention( regar$le!! o !ie( location(an$6or eDten!ion 8!trong recommen$ation( mo$erate F"ality o ei$ence94

334 ;n !table #atient! /ith inecte$ necro!i!( !"rgical( ra$iologic( an$6or en$o!co#ic $rainage !ho"l$ be $elaye$ #reerably or more than /eeB! to allo/

liF"eication o the content! an$ the $eelo#ment o a i bro"! /all aro"n$ the necro!i! 8/alle$:o necro!i!9 8!trong recommen$ation( lo/ F"ality oei$ence94

34 ;n !ym#tomatic #atient! /ith inecte$ necro!i!( minimally ina!ie metho$! o necro!ectomy are #reerre$ to o#en necro!ectomy 8!trong recommen:

$ation( lo/ F"ality o ei$ence94

A'( ac"te #ancreat iti! CT( com#"te$ tomogra#hy ERC'( en$o!co#ic retrogra$e cholangio#ancreatogra#hy &RC'( magnetic re!onance cholangio#ancreatogra#hy4

li#a!e co"l$ not reach con!en!"! on a##ro#riate "##er limit! o

normal 81594 A!!ay! o many other #ancreatic enyme! hae

been a!!e!!e$ $"ring the #a!t 1@ year!( b"t none !eem! to

oer better $iagno!tic al"e than tho!e o !er"m amyla!e an$

li#a!e 81=94 Altho"gh mo!t !t"$ie! !ho/ a $iagno!tic eicacy o

greater than 3@ time! the "##er limit o normal( clinician!

m"!t con!i$er the clinical con$ition o the #atient /hen

eal"at: ing amyla!e an$ li#a!e eleation!4 .hen a $o"bt

regar$ing the $iagno!i! o A' eDi!t!( ab$ominal imaging( !"ch

a! CECT( i! r ecommen$e$4

);AGNOS;S% A-)O&;NAL ;&AG;NG

Ab$ominal imaging i! "!e"l to conirm the $iagno!i! o A'4CECT #roi$e! oer =0 !en!itiity an$ !#eciicity or the

$iag: no!i! o A' 82094 Ro"tine "!e o CECT in #atient! /ith

A' i! "n/arrante$( a! the $iagno!i! i! a##arent in many

#atient! an$ mo!t hae a mil$( "ncom#licate$ co"r!e4

*o/eer( in a #atient ailing to im#roe ater 5?2 8e4g4(

#er!i!tent #ain( eer( na"!ea( "nable to begin oral ee$ing9(

CECT or &R; imaging i! r ecom: men$e$ to a!!e!! local

com#lication! !"ch a! #ancreatic necro!i! 8212394 Com#"te$

tomogra#hy 8CT9 an$ &R; are com#ar a ble in the early

a!!e!!ment o A' 8294 &R;( by em#loying magnetic re!onance

cholangio#ancreatogra#hy 8&RC'9( ha! the a$antage

o $etecting chole$ocholithia!i! $o/n to 3 mm $iameter an$ #an: creatic $"ct $i!r"#tion /hile #roi$ing high:F"ality

imaging or $iagno!tic an$6or !eerity #"r#o!e!4 &R; i! hel#"l

in #atient! /ith a contra!t allergy an$ renal in!"iciency /here

T2:/eighte$ image! /itho"t ga$olini"m contra!t can

$iagno!e #ancr eatic necro!i! 8294

ET;OLOGY

Recommendations

14 Tran!ab$ominal "ltra!o"n$ !ho"l$ be #erorme$ in all

#atient! /ith A' 8!trong recommen$ation( lo/ F"ality o

ei$ence9424 ;n the ab!ence o gall!tone! an$6or hi!tory o

!igniicant hi!tory o alcohol "!e( a !er"m triglyceri$e

!ho"l$ be obtaine$ an$ con!i$ere$ the etiology i

1(000 mg6$l4

8con$itional recommen$ation( mo$erate F"ality o ei$ence94

34 ;n a #atient 0 year! ol$( a #ancreatic t"mor !ho"l$ be

con!i$ere$ a! a #o!!ible ca"!e o A' 8con$itional

r ecommen: $ation( lo/ F"ality o ei$ence94

4 En$o!co#ic ine!tigation o an el"!ie etiology in #atient!

/ith A' !ho"l$ be limite$( a! the ri!B! an$ beneit! o

ine!tigation in the!e #atient! are "nclear 8con$itional

recommen$ation( lo/ F"ality o ei$ence94

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@4 'atient! /ith i$io#athic A' 8;A'9 !ho"l$ be reerre$

to center! o eD#erti!e 8con$itional recommen$ation(

lo/ F"ality o ei$ence94

>4 Genetic te!ting may be con!i$ere$ in yo"ng #atient!

8 H 30 year! ol$9 i no ca"!e i! ei$ent an$ a amily hi!tory

o #ancreatic $i!ea!e i! #re!ent 8con$itional

r ecommen$ation( lo/ F"ality o ei$ence94

ET;OLOGY% GALLSTONES AN) ALCO*OL

The etiology o A' can be rea$ily e!tabli!he$ in mo!t #atient!4

The mo!t common ca"!e o A' i! gall!tone! 80?09 an$ alco:

hol 82@3@9 82@2?94 -eca"!e o the high #realence an$

im#or : tance o #reenting rec"rrent $i!ea!e( ab$ominal

"ltra!o"n$ to eal"ate or cholelithia!i! !ho"l$ be #erorme$

on all #atient! /ith A' 8253094 ;$entiication o gall!tone!

a! the etiology !ho"l$ #rom#t reerral or cholecy!tectomy to

#reent r ec"rr ent attacB! an$ #otential biliary !e#!i! 82=(3094

Gall!tone #ancr eatiti! i! "!"ally an ac"te eent an$ re!ole!/hen the !tone i! r emoe$ or #a!!e! !#ontaneo"!ly4

Alcohol:in$"ce$ #ancreatiti! oten manie!t! a! a !#ectr "m(

ranging rom $i!crete e#i!o$e! o A' to chronic irreer!ible

!ilent change!4 The $iagno!i! !ho"l$ not be entertaine$ "nle!! a

#er !on ha! a hi!tory o oer @ year! o heay alcohol

con!"m#tion 83194 I*eayJ alcohol con!"m#tion i! generally

con!i$ere$ to be @0 g #er $ay( b"t i! oten m"ch higher

83294 Clinically ei$ent A' occ"r! in H @ o heay $rinBer!

8339 th"!( there are liBely other actor! that !en!itie in$ii$"al!

to the eect! o alcohol( !"ch a! genetic actor! an$ tobacco "!e

82?(33(394

OT*ER CA:

merca#to#"rine( aathio#rine( an$ )); 82(3: $i$eoDyino!ine9

can clearly ca"!e A'( there are limite$ $ata !" #: #orting mo!t

me$ication! a! ca"!atie agent! 83@94 'rimary an$ !econ$ary

hy#ertriglyceri$emia can ca"!e A' ho/eer( the!e acco"nt or

only 1 o ca!e! 83>94 Ser"m triglyceri$e! !ho"l$ ri!e aboe1(000 mg6$l to be con!i$ere$ the ca"!e o A' 835(3=94 A

lacte!cent 8milBy9 !er"m ha! been ob!ere$ in a! many a! 20

o #atient! /ith A'( an$ thereore a a!ting triglyceri$e leel

!ho"l$ be re:eal"ate$ 1 month ater $i!charge /hen

hy#ertriglyceri$emia i! !"!#ecte$ 8094 Altho"gh mo!t $o not(

any benign or malignant ma!! that ob!tr"ct! the main

#ancreatic can re!"lt in A'4 ;t ha! been e!timate$ that @1

o #atient! /ith benign or malignant #ancreatobiliary t"mor!

#re!ent /ith a##arent ;A' 81394 *i!: torically(

a$enocarcinoma o the #ancrea! /a! con!i$ere$ a $i!: ea!e o

ol$ age4 *o/eer( increa!ingly #atient! in their 0!Pan$

occa!ionally yo"ngerPare #re!enting /ith #ancreatic cancer4

Thi! entity !ho"l$ be !"!#ecte$ in any #atient 0 year! o ag

/ith i$io#athic #ancreatiti!( e!#ecially tho!e /ith a #rolonge$ or


7/21

rec"rrent co"r!e 82?((@94 Th"!( a contra!t:enhance$ CT

!can or &R; i! nee$e$ in the!e #atient!4 A more eDten!ie

eal"ation incl"$ing en$o!co#ic "ltra!o"n$ 8E94

;);O'AT*;

C A'

;A' i! $eine$ a! #ancreatiti! /ith no etiology e!tabli!he$ater initial laboratory 8incl"$ing li#i$ an$ calci"m leel9

an$ imag: ing te!t! 8tran!ab$ominal "ltra!o"n$ an$ CT

in the a ##r o #r i: ate #atient9 8?94 ;n !ome #atient! an

etiology may eent"ally be o"n$( yet in other! no $einite

ca"!e i! eer e!tabli!he$4 'atient! /ith ;A' !ho"l$ be

eal"ate$ at center! o eDcellence oc"!ing on #ancreatic

$i!ea!e( #roi$ing a$ance$ en$o!co#y !erice! an$ a

combine$ m"lti$i!ci#linary a ##r oach4

Anatomic an$ #hy!iologic anomalie! o the #ancrea!

occ"r in 101@ o the #o#"lation( incl"$ing #ancrea!

$ii!"m an$ !#hincter o O$$i $y!"nction 8594 ;t

remain! controer!ial i the!e $i!or$er! alone ca"!e A'8=94 There may be a com bination o actor!( incl"$ing

anatomic an$ genetic( that #re$i!#o!e to the $eelo#ment

o A' in !"!ce#tible in$ii$"al! 8594 En$o!co#ic thera#y(

oc"!ing on treating #ancrea! $ii!"m an$6or !#hincter o

O$$i $y!"nction( carrie! a !igniicant ri!B o #reci#itating

A' an$ !ho"l$ be #erorme$ only in !#ecialie$ "nit!

8@0(@194 The inl": ence o genetic $eect!( !"ch a! cationic

try#!inogen m"tation!( S';NQ( or C+TR m"tation!( in

ca"!ing A' i! being increa!ingly recognie$4 The!e $eect!(

"rthermore( may al!o increa!e the ri!B o A' in #atient!

/ith anatomic anomalie!( !"ch a! #ancr ea! $ii!"m 8594

*o/eer( the role o genetic te!ting in A' ha! yet to be

$etermine$( b"t may be "!e"l in #atient! /ith more than one

amily member /ith #ancreatic $i!ea!e 8394 ;n$ii$"al! /ith

;A' an$ a amily hi!tory o #ancreatic $i!ea!e! !ho"l$ be

reerre$ or ormal genetic co"n!eling4

;N;T;AL ASSESS&ENT AN) R;SQ STRAT;+;CAT;ON

Recommendations

14 *emo$ynamic !tat"! !ho"l$ be a!!e!!e$ imme$iately " #on

#re!entation an$ re!"!citatie mea!"re! beg"n a! nee$e$


24 Ri!B a!!e!!ment !ho"l$ be #erorme$ to !tratiy #atient!

into higher: an$ lo/er:ri!B categorie! to a!!i!t triage(

!"ch a! a$mi!!ion to an inten!ie care !etting

8con$itional recommen$ation( lo/ to mo$erate F"ality o

ei$ence94

34 'atient! /ith organ ail"re !ho"l$ be a$mitte$ to an

inten!ie care "nit or interme$iary care !etting /heneer

#o!!ible 8!trong recommen$ation( lo/ F"ality oei$ence94

S


8/21

#atient! ty#ically /o"l$ hae !"b!tantially im#roe$ an$ beg"n

reee$ing4 ;n #atient! /ith !eere $i!ea!e( t/o #ha!e! o A' ar e

recognie$% early 8/ithin the ir!t /eeB9 an$ late4 Local com#li:

cation! incl"$e #eri#ancreatic l"i$ collection! an$ #ancr eatic

an$ #eri#ancreatic necro!i! 8!terile or inecte$94 &o!t #atient!

/ith !eere $i!ea!e #re!ent to the emergency room /ith no

or gan ail"re or #ancreatic necro!i! "nort"nately( thi! ha! le$

to many error! in clinical management o thi! $i!ea!e 8@294

The!e er r or ! incl"$e ail"re to #roi$e a$eF"ate hy$ration(

ail"re to $iagno!e an$ treat cholangiti!( an$ ail"re to treat

early organ ail"re4 +or thi! rea!on( it i! critical or the clinician

to recognie the im#or : tance o not al!ely labeling a #atient

/ith mil$ $i!ea!e /ithin the ir!t 5 h o a$mi!!ion or A'4

Seere A' occ"r! in 1@20 o #atient! 8@394 Seere A' i!

$eine$ by the #re!ence o #er!i!tent 8ail! to re!ole /ithin

5 h9 organ ail"re an$6or $eath 8>94 *i!torically( in the

ab!ence o organ ail"re( local com#lication! rom #ancreatiti!(

!"ch a! #ancreatic necro!i!( /ere al!o con!i$ere$ !eere $i!ea!e

8@(>(@394 *o/eer( the!e local com#lication! 8incl"$ing

#ancreatic necr o: !i! /ith or /itho"t tran!ient organ ail"re9$eine mo$erately !eere A' 8!ee Ta)le 694 &o$erately !eere

ac"te #ancreatiti! i! characterie$ by the #re!ence o tran!ient

organ ail"re or local or !y!tematic com#lication! in the

ab!ence o #er!i!tent or gan ail"re 8>94 An eDam#le o a #atient

/ith mo$erately !eere ac"te #ancreatiti! i! one /ho ha!

#eri#ancreatic l"i$ collection! an$ #rolonge$ ab$ominal #ain(

le"Bocyto!i! an$( eer( ca"!ing the #atient to remain

ho!#italie$ or ?:10 $ay!4 ;n the ab!ence o #er : !i!tent organ

ail"re( mortality in #atient! /ith thi! entity i! le!! than !eere

ac"te #ancreatiti!4 ; #er!i!tent organ ail"re $eelo#! in a

#atient /ith necrotiing #ancreatiti!( it i! then con!i$er e$ !eere

$i!ea!e4

Organ ail"re ha$ #reio"!ly been $eine$ a! !hocB 8!y!tolic

bloo$ #re!!"re H =0 mm *g9( #"lmonary in!"iciency

8'aO2

H >0 mm *g9( renal ail"re 8creatinine 2 mg6$l ater r ehy$ration9(

an$6or ga!trointe!tinal blee$ing 8 @00 ml o bloo$ lo!!62 h9

8@394 The Rei!e$ Atlanta Criteria no/ $eine organ ail"re a! a

!core o 2 or more or one o the!e organ !y!tem! "!ing the

mo$iie$ &ar!hall !coring !y!tem 8>(594 The a"thor! eel that

rather than calc"late a &ar!hal !core 8/hich may be com#leD

or the b"!y clinician9( relying on the ol$er Atlanta $einition!

/o"l$ be a! "!e"l4 +"rther !t"$y i! nee$e$ to ali$ate the nee$

or "!ing the &ar!hal !core4

'ancreatic necro!i! i! $eine$ a! $i"!e or ocal area! o non:

iable #ancreatic #arenchyma 3 cm in !ie or 30 o the

#an: crea! 8@394 'ancreatic necro!i! can be !terile or inecte$

8$i!c"!!e$ belo/94 ;n the ab!ence o #ancreatic necro!i!( in mil$

$i!ea!e the e$emato"! #ancrea! i! $eine$ a! inter!titial

#ancreatiti!4 Altho"gh there i! !ome correlation bet/een

inection( #ancreatic necro!i!( ho!#ital length o !tay( an$ organ

ail"re( both #atient! /ith !terile necro!i! an$ inecte$ necro!i!

may $eelo# organ ail"re 8@@(@>94 The #re!ence o inection

/ithin the necro!i! #robably $oe! not increa!e the liBelihoo$ o

#re!ent or "t"re organ ail"re4 'atient! /ith !terile necro!i! can

!"er rom organ ail"re an$ a##ear a! ill clinically a! tho!e

#atient! /ith inecte$ necro!i!4 'er!i!tent or gan ail"re i! no/$eine$ by a &o$iie$ &ar!hal Score 8>(594

Ta)le 6. Definitions of se(erit* in acute $ancreatitis5 com$arison

of Atlanta an# recent re(ision

Atlanta criteria %";;6& Atlanta Re(ision %/7"6&

-il# acute $ancreatitis -il# acute $ancreatitis

Ab!ence o organ ail"re Ab!ence o organ ail"re

Ab!ence o local com#lication! Ab!ence o local com#lication!

!e(ere acute $ancreatitis &o$erately !eere ac"te #ancreatiti!

14 Local com#lication! AD,0(>194 ;n general( A':!#eciic !coring !y!tem! hae a

limite$ al"e( a! they #r oi$e little a$$itional inormation to the

clinician in the eal"ation o #atient! an$ may $elay a##ro#riate

management 8@294Altho"gh laboratory te!ting !"ch a! the hematocrit an$ bloo$

"rea nitrogen 8-2(>39( no

la borator y te!t i! #ractically aailable or con!i!tently acc"rate to

#re$ict !eer: ity in #atient! /ith A' 8>>>94 Een the ac"te:

#ha!e r eactant C:reactie #rotein 8CR'9( the mo!t /i$ely

!t"$ie$ inlammator y marBer in A'( i! not #ractical a! it taBe!

?2 h to become acc"rate 8@94 CT an$6or &R; imaging al!o

cannot reliably $eter mine !eerity early in the co"r!e o A'( a!

necro!i! "!"ally i! not #r e!ent on a$mi!!ion an$ may $eelo#

ater 2 5 h 82(>?94 Th"!( in the ab!ence o any aailable te!t to

$etermine !eerity( clo!e eDamina: tion to a!!e!! early l"i$

lo!!e!( hy#oolemic !hocB( an$ !ym#tom! !"gge!tie o organ

$y!"nction i! cr"cial4

OL


9/21

#atient! /ith #er!i!tent S;RS( #artic"larly tho!e /ho are

tachy#nic an$6or tachycar$ic( !ho"l$ be a$mitte$ to an

inten!ie care "nit or !imilar "nit or aggre!!ie intraeno"!

hy$ration an$ clo!e monitoring4

;N;T;AL &ANAGE&ENT

&"lti#le or eDten!ie eDtra#ancreatic collection! 8>?9

-&;( bo$y ma!! in$eD -29(

#re!ence o #le"ral e"!ion! an$6or iniltrate! 8?39( altere$

mental !tat"! 8>=9( an$ other actor! 8@(?29 8Ta)le 694

)"ring the early #ha!e o the $i!ea!e 8/ithin the ir!t /eeB9($eath occ"r! a! a re!"lt o the $eelo#ment( #er!i!tence( an$

#r o: gre!!ie nat"re o organ $y!"nction 8?@(?>94 The

$eelo#ment o organ ail"re a##ear! to be relate$ to the

$eelo#ment an$ #er : !i!tence o S;RS4 The reer!al o an$

early organ ail"re ha! been !ho/n to be im#ortant in

#reenting morbi$ity an$ mortality in #atient! /ith A' 8??(?594

Altho"gh the #re!ence o S;RS $"r ing the initial 2 h ha! a

high !en!itiity or #re$icting organ ail"re an$ mortality( the

#re!ence o S;RS lacB! !#eciicity or !eere $i!: ea!e 8194 The

lacB o !#eciicity i! $"e to the act that the #r e!: ence o S;RS i!

not a! im#ortant a! it! #er!i!tence4 +or thi! r ea!on(

Recommendations

14 Aggre!!ie hy$ration( $eine$ a! 2@0 @00 ml #er ho"r o

i!o: tonic cry!talloi$ !ol"tion !ho"l$ be #roi$e$ to all

#atient!( "nle!! car$ioa!c"lar( renal( or other relate$

comorbi$ actor ! eDi!t4 Early aggre!!ie intraeno"!

hy$ration i! mo!t

beneicial $"ring the ir!t 12 2 h( an$ may hae little

beneit beyon$ thi! time #erio$ 8!trong recommen$ation(

mo$erate F"ality o ei$ence94

24 ;n a #atient /ith !eere ol"me $e#letion( manie!t a! hy #o:

ten!ion an$ tachycar$ia( more ra#i$ re#letion 8bol"!9 may

be nee$e$ 8con$itional recommen$ation( mo$erate F"alityo ei$ence94

34 Lactate$ Ringer M! !ol"tion may be the #reerre$ i!otonic

cry!talloi$ re#lacement l"i$ 8con$itional r ecommen$ation(


4 +l"i$ reF"irement! !ho"l$ be rea!!e!!e$ at reF"ent interal!

/ithin > h o a$mi!!ion an$ or the neDt 2 5 h4 The goal

o aggre!!ie hy$ration !ho"l$ be to $ecrea!e the -2(>3(51(529( e#i$emiologic !t"$ie! 8@=9( an$ both

retro!#ectie an$ #ro!#ectie clinical trial! 8=(5394

The rationale or early aggre!!ie hy$ration in A' ari!e!

r om ob!eration o the reF"ent hy#oolemia that occ"r! rom

m"lti #le actor! aecting #atient! /ith A'( incl"$ing omiting(

re$"ce$ or al intaBe( thir$ !#acing o l"i$!( increa!e$ re!#iratory

lo!!e!( an$ $ia: #hore!i!4 ;n a$$ition( re!earcher! hy#othe!ie

that a com bination o microangio#athic eect! an$ e$ema o theinlame$ #ancr ea! $ecrea!e! bloo$ lo/( lea$ing to increa!e$

cell"lar $eath( necr o: !i!( an$ ongoing relea!e o #ancreatic

enyme! actiating n"mer : o"! ca!ca$e!4 ;nlammation al!o

increa!e! a!c"lar #ermeability( lea$ing to increa!e$ thir$

!#ace l"i$ lo!!e! an$ /or!ening o #ancreatic hy#o#er"!ion

that lea$! to increa!e$ #ancr eatic #arenchymal necro!i! an$ cell

$eath 8594 Early aggre!!ie intra: eno"! l"i$ re!"!citation

#roi$e! micro: an$ macrocir c"lator y !"##ort to #reent

!erio"! com#lication! !"ch a! #ancr eatic necro!i! 81094

Altho"gh there are limite$ #ro!#ectie $ata that

aggre!!ie intraeno"! hy$ration can be monitore$ an$6or

g"i$e$ by

Ta)le 1. Clinical fin#ings associate# with a se(ere course for

initial ris3 assessmenta

Patient characteristics

Age @@ year! 8@3(@?9

Obe!ity 8-&; 30 Bg6m29 8>59

Altere$ mental !tat"! 8>=9Comorbi$ $i!ea!e 8@39

The systemic inflammatory response syndrome (SIRS) 8>(@3(@(?0(?19're!ence o 2 o the ollo/ing criteria%

#"l!e =0 beat! 6min

re!#iration! 206min or 'aCO 32 mm *g2

tem#erat"re 35 C or H 3> C

.-C co"nt 12(000 or H (000 cell!6mm3 or 10 immat"re

ne"tro#hil! 8ban$!9

Laboratory findings

-39

Ri!ing -39

*CT 8>29

Ri!ing *CT 8>29

Eleate$ creatinine 8?29

Radiology findings

'le"ral e"!ion! 8?39

'"lmonary iniltrate! 8@39


10/21

laboratory marBer!( the "!e o hematocrit 8>29( -3(539( an$ creatinine 8?29 a! !"rrogate marBer! or !"cce!!"l

hy$ration ha! been /i$ely recommen$e$ 810(1@(@2(@394

Altho"gh no irm recommen$ation! regar$ing ab!ol"te

n"mber! can be ma$e at thi! time( the goal to $ecrea!e

hematocrit 8$emon!trating hemo: $il"tion9 an$ -9( other !t"$ie! hae !"gge!te$

that aggre!!ie hy$ration may be a!!ociate$ /ith an increa!e$

morbi$ity an$ mortality 85?(5594 The!e ariable !t"$y in$ing!

may be #artly eD#laine$ by critical $ierence! in !t"$y $e!ign4

Altho"gh the!e !t"$ie! rai!e concern! abo"t the contin"o"!

"!e o aggre!!ie hy$ration oer 5 h( the role o early hy$ra:

tion 8/ithin the ir!t > 12 h9 /a! not a$$re!!e$ in the!e nega:

tie !t"$ie!4 ;n a$$ition( the!e negatie !t"$ie! incl"$e$ !icBer

#atient! /ho /o"l$ hae reF"ire$ large ol"me! o hy$ration

by the 5 h time #oint 85?(5594 Con!i!tently( the h"man

!t"$: ie! in A' that oc"!e$ on the initial rate o hy$ration

early in the co"r!e o treatment 8/ithin the ir!t 2 h9

$emon!trate$ a $ecrea!e in both morbi$ity an$ mortality

8=(5@(5>94 Altho"gh the total ol"me o hy$ration at 5 h

ater a$mi!!ion a ##ear ! to hae little or no im#act on #atient

o"tcome( early aggre!!ie intraeno"! hy$ration( $"ring the

ir!t 122 h( /ith clo!e moni: toring i! o #aramo"nt

im #ortance4

;n a /ell:$e!igne$ #ro!#ectie ran$omie$ trial( hy$ration

/ith a lactate$ Ringer M! !ol"tion a##ear! to be more beneicial(

re!"lting in e/er #atient! $eelo#ing S;RS a! com#are$ /ith

#atient! receiing normal 804=9 !aline 85394 The beneit o

"!ing lactate$ Ringer M! !ol"tion in large:ol"me re!"!citationha! been !ho/n in other $i!ea!e !tate! to lea$ to better electr o:

lyte balance an$ im#roe$ o"tcome! 85=(=094 ;n A'( there ar e

a$$itional theoretical beneit! to "!ing the more #*:balance$

lactate$ R inger M! !ol"tion or l"i$ re!"!citation com#are$ /ith

normal !aline4 Lo/ #* actiate! the try#!inogen( maBe! the

acinar cell! more !"!ce#tible to in7"ry an$ increa!e! the !eerity

o e!tabli!he$ A' in eD#erimental !t"$ie!4 Altho"gh both ar e

i!otonic cry!talloi$ !ol"tion!( normal !aline gien in large ol:

"me! may lea$ to the $eelo#ment o a non:anion ga#( hy #er :

chloremic metabolic aci$o!i! 85394

;t i! im#ortant to recognie that aggre!!ie early hy$ration

/ill reF"ire ca"tion or certain gro"#! o #atient!( !"ch a! the

el$erly( or tho!e /ith a hi!tory o car$iac an$6or renal $i!ea!e in

or$er to aoi$ com#lication! !"ch a! ol"me oerloa$(

#"lmonary e$ema( an$ ab$ominal com#artment !yn$rome

8=194 &ea!"rement o the central eno"! #re!!"re ia a centrally

#lace$ catheter i! mo!t commonly "!e$ to $etermine ol"me

!tat"! in thi! !etting4 *o/: eer( $ata in$icate that the

intrathoracic bloo$ ol"me in$eD may hae a better correlation

/ith car$iac in$eD than central eno"! #re!!"re4 &ea!"rement

o intrathoracic bloo$ ol"me in$eD may thereore allo/ more

acc"rate a!!e!!ment o ol"me !tat"! or #atient! manage$ in

the inten!ie care "nit4 'atient! not r e!#on$: ing to intraeno"!

hy$ration early 8/ithin > 12 h9 may not beneit rom contin"e$

aggre!!ie hy$ration4

ERC' ;N A'

The role o ERC' in A' i! relate$ to the management o

chole$o: cholithia!i!4 Altho"gh ERC' can be "!e$ to i$entiy

#ancr eatic $"ctal $i!r"#tion in #atient! /ith !eere A'(

#o!!ibly lea$ing to interention! or the !o:calle$ $i!locate$

$"ct !yn$rome( a con!en!"! ha! neer emerge$ that ERC'

!ho"l$ be #er or me$ ro"tinely or thi! #"r#o!e 8@294

Recommendations

14 'atient! /ith A' an$ conc"rrent ac"te cholangiti! !ho"l$

"n$ergo ERC' /ithin 2 h o a$mi!!ion 8!trong r ecommen:

$ation( mo$erate F"ality o ei$ence94

24 ERC' i! not nee$e$ early in mo!t #atient! /ith gall!tone

#ancreatiti! /ho lacB laboratory or clinical ei$ence o

ongoing biliary ob!tr"ction 8!trong r ecommen$ation(


34 ;n the ab!ence o cholangiti! an$6or 7a"n$ice( &RC' or

E1( P 0400394 &ortality /a! not

!igniicantly $ierent in the t/o gro"#!4 +an et al. 8=9

r e #orte$ a !t"$y o 1=@ #atient! /ith !"!#ecte$ biliary

#ancreatiti! !trati: ie$ or !eerity accor$ing to R an!onM! criteria4

'atient! in the !t"$y gro"# "n$er/ent ERC' /ithin 2 h o

a$mi!!ion an$ tho!e in the control gro"# /ere oere$

con!eratie management4 The contr ol gro"# /a! oere$ ERC' i

ac"te cholangiti! $eelo#e$4 Tho!e /ho "n$er/ent early ERC'

ha$ e/er com#lication! 813 !4 @( P 0400294

OL


11/21

-a!e$ on the!e !t"$ie!( it /a! "nclear /hether #atient! /ith

!eere A' in the ab!ence o ac"te cholangiti! beneit rom early

ERC'4 Thereore( +ol!ch et al. 8=@9 organie$ a m"lticenter

!t"$y o ERC' in ac"te biliary #ancreatiti! that eDcl"$e$

#atient! mo!t liBely to beneit( namely tho!e /ith a !er"m

bilir"bin @ mg6$l4 Th"!( #atient! /ith ac"te cholangiti!

an$6or obio"! biliary tree ob!tr"ction "n$er/ent early

ERC' an$ /ere not incl"$e$ in the !t"$y4 Thi! !t"$y oc"!e$

on $etermining the beneit o early ERC' in #reenting !eere

A' in the ab!ence o biliary ob!tr"ction4 Altho"gh thi! !t"$y

ha! been /i$ely criticie$ or $e!ign la/! an$ the "n"!"ally

high mortality o #atient! /ith mil$ $i!ea!e 85 com#are$

/ith an eD#ecte$ 19( no beneit in morbi$ity an$6or mortality

/a! !een in #atient! /ho "n$er /ent early ERC'4 +rom thi!

!t"$y( it a##ear! that the beneit o early ERC' i! !een in

#atient! /ith A' com#licate$ by ac"te cholangiti! an$ biliary

tree ob!tr"ction( b"t not !eere A' in the ab!ence o ac"te

cholangiti!4

&ore recent !t"$ie! hae conirme$ that early ERC' /ithin 2

h o a$mi!!ion $ecrea!e! morbi$ity an$ mortality in #atient!/ith A' com#licate$ by biliary !e#!i! 8=>(=?94 A $ilate$ biliary

tree in the ab!ence o an eleate$ bilir"bin an$ other !ign! o

!e#!i! !ho"l$ not be con"!e$ /ith cholangiti!( b"t may

in$icate the #re!ence o a common bile $"ct !tone4 ;n #atient!

/ith biliary #ancr eatiti! /ho hae mil$ $i!ea!e( an$ in #atient!

/ho im#roe( ERC' beore cholecy!tectomy ha! been !ho/n to

be o limite$ al"e an$ may be harm"l4 Nonina!ie imaging

!t"$ie! are the #reerre$ $iag: no!tic mo$alitie! in the!e #atient!

8E5 #atient!(

!ho/e$ that #ancreatic $"ct !tent #lacement aor$! a t/o:

ol$ $ro# in the inci$ence o #o!t:ERC' #ancreatiti! 8241

!4 12 P 0400= o$$! ratio% 04( =@ coni$ence interal%

042045194 Altho"gh "rther !t"$y i! nee$e$( !maller 3 +r ench

8+r9 "nlange$ #ancreatic !tent! a##ear to lo/er the ri!B o

#o!t:ERC' #ancreatiti! 8 P 040039( #a!! more !#ontaneo"!ly

8 P 0400019( an$ ca"!e le!! #ancreatic $"ctal change! 82

!4

509 a! com#are$ /ith larger +r( @ +r( or > +r !tent! 810>94

*o/eer( 3 +r #ancreatic !tent #lacement i! more technically

$eman$ing beca"!e o the nee$ to "!e a ery lo##y 804015:inch

$iameter9 g"i$e/ire4 Altho"gh #ro#hylactic #ancreatic $"ct

!tenting i! a co!t:eectie !trategy or the #reention o #o!t:

ERC' #ancreatiti! or high:ri!B #atient! 810?9( a higher inci:

$ence o !eere #ancreatiti! ha! been re#orte$ in #atient! /ith

aile$ #ancreatic $"ct !tenting 810594 'ancreatic $"ct !tenting i!

not al/ay! technically ea!ible( /ith re#orte$ ail"re rate! rang:

ing rom to 10 810594 ;n a$$ition( long:term com#lication!

rom #ancreatic $"ct !tenting( !"ch a! chronic #ancreatiti!( may

occ"r an$ "rther !t"$y i! nee$e$ 8=94Altho"gh a large n"mber o #harmacologic interention! or

#ro#hylaDi! again!t #o!t:ERC' #ancreatiti! hae been !t"$ie$

8@09( the re!"lt! o the !t"$ie! hae been largely $i!a ##ointing4

The mo!t #romi!ing gro"# o $r"g! to atten"ate the inlamma:

tory re!#on!e o A' are NSA;)! 810=(11094 T/o clinical trial!

hae !ho/n that a 100 mg rectal !"##o!itory o $icloenac

r e$"ce! the inci$ence o #o!t:ERC' #ancreatiti! 8111(11294

;n a$$i: tion( a recent m"lticenter( $o"ble:blin$( ran$omie$

#lacebo controlle$ trial o >02 #atient! "n$ergoing a high:

ri!B ERC' $emon!trate$ a !igniicant re$"ction o #o!t:ERC'

#ancr eati: ti! in #atient! gien #o!t#roce$"re rectal

in$omethacin 811394 ;t i! im#ortant to note that thi! !t"$y

incl"$e$ only #atient! at a


12/21

high ri!B o $eelo#ing #o!t:ERC' #ancreatiti! an$ !eere A'(

/hich i! the #o#"lation that /o"l$ beneit the mo!t4 .hen

con!i$ering the co!t!( ri!B!( an$ #otential beneit! reie/e$

in the #"bli!he$ literat"re( rectal $icloenac an$6or in$o:

methacin !ho"l$ be con!i$ere$ beore ERC'( e!#ecially in

high:ri!B #atient!4 Altho"gh "rther !t"$y i! nee$e$ to $eine

the o#timal $o!e( at #re!ent it i! rea!onable to con!i$er #lace:

ment o t/o in$omethacin @0 mg !"##o!itorie! 8total 100

mg9 ater ERC' in #atient! at a high ri!B o $eelo#ing #o!t:

ERC' A'4 *o/eer( "ntil "rther !t"$y i! #erorme$( the

#lacement o rectal NSA;)! $oe! not re#lace the nee$ or a

#ancreatic $"ct !tent in the a##ro#riate high:ri!B #atient4

T*E ROLE O+ ANT;-;OT;CS ;N A'

Recommendations

14 Antibiotic! !ho"l$ be gien or an eDtra#ancreatic inection(

!"ch a! cholangiti!( catheter:acF"ire$ inection!(

bacteremia( "rinary tract inection!( #ne"monia 8!trongr ecommen$a: tion( mo$erate F"ality o ei$ence94

24 Ro"tine "!e o #ro#hylactic antibiotic! in #atient! /ith

!eere A' i! not recommen$e$ 8!trong recommen$ation(


34 The "!e o antibiotic! in #atient! /ith !terile necro!i! to

#reent the $eelo#ment o inecte$ necro!i! i! not

recommen$e$ 8!trong recommen$ation( mo$erate F"ality

o ei$ence94

4 ;necte$ necro!i! !ho"l$ be con!i$ere$ in #atient! /ith

#ancreatic or eDtra#ancreatic necro!i! /ho $eteriorate or

ail to im#roe ater ?10 $ay! o ho!#italiation4 ;n

the!e #atient!( either 8i9 initial CT:g"i$e$ ine:nee$le

a!#iration

8+NA9 or Gram !tain an$ c"lt"re to g"i$e "!e o

a ##r o #r iate antibiotic! or 8ii9 em#iric "!e o antibiotic! ater

obtaining nece!!ary c"lt"re! or inectio"! agent!( /itho"t

CT +NA( !ho"l$ be gien 8!trong recommen$ation(

mo$erate ei$ence94

@4 ;n #atient! /ith inecte$ necro!i!( antibiotic! Bno/n to

#ene: trate #ancreatic necro!i!( !"ch a! carba#enem!(

F"inolone!( an$ metroni$aole( may be "!e"l in $elaying or

!ometime! totally aoi$ing interention( th"! $ecrea!ing

morbi$ity an$ mortality 8con$itional recommen$ation(


>4 Ro"tine a$mini!tration o anti"ngal agent! along /ith #ro#hylactic or thera#e"tic antibiotic! i! not r ecommen$e$

8con$itional recommen$ation( lo/ F"ality o ei$ence94

Infectious com$lications

;nectio"! com#lication!( both #ancreatic 8inecte$ necro!i!9

an$ eDtra#ancreatic 8#ne"monia( cholangiti!( bacteremia( "r i:

nary tract inection!( an$ !o on9( are a ma7or ca"!e o morbi$ity

an$ mortality in #atient! /ith A'4 &any inection! are

ho!#ital: acF"ire$ an$ may hae a ma7or im#act on mortality

81194 +eer( tachycar$ia( tachy#nea( an$ le"Bocyto!i!

a!!ociate$ /ith S;RS

that may occ"r early in the co"r!e o A' may be

in$i!ting"i!ha ble rom !e#!i! !yn$rome4 .hen an inection i!

!"!#ecte$( antibiotic! !ho"l$ be gien /hile the !o"rce o the

inection i! being ine!: tigate$ 8@394 *o/eer( once bloo$ an$

other c"lt"re! are o"n$ to be negatie an$ no !o"rce o

inection i! i$entiie$( antibiotic! !ho"l$ be $i!contin"e$4

'REENT;NG T*E ;N+ECT;ON O+ STER;LE

NECROS;S

The #ara$igm !hit an$ controer!y oer "!ing antibiotic! in

A' ha! centere$ on #ancreatic necro!i!4 .hen com#are$ /ith

#atient! /ith !terile necro!i!( #atient! /ith inecte$ #ancr eatic

necro!i! hae a higher mortality rate 8mean 30( range 1>=9

8@394 +or thi! rea!on( #reenting inection o #ancreatic necro!i!

i! im#ortant4 Altho"gh it /a! #reio"!ly beliee$ that

inectio"! com#lication! occ"r late in the co"r!e o the $i!ea!e

811@(11>9( a recent reie/ o"n$ that 2? o all ca!e!

o inecte$ necro!i! occ"r /ithin the ir!t 1 $ay! 811?9 in

another !t"$y( nearly hal o all inection! a##ear to occ"r /ithin ? $ay! o a$mi!!ion 811594

Altho"gh early "nblin$e$ trial! !"gge!te$ that a$mini!tration

o antibiotic! may #reent inectio"! com#lication! in #atient!

/ith !terile necro!i! 811=(1209( !"b!eF"ent( better:$e!igne$ trial!

hae con!i!tently aile$ to conirm an a$antage 812112@94

-eca"!e o the con!i!tency o #ancreatic necro!i!( e/

antibiotic! #enetrate /hen gien intraeno"!ly4 The antibiotic!

!ho/n to #enetrate an$ "!e$ in clinical trial! incl"$e

carba#enem!( F"inolone!( metro: ni$aole( an$ high:$o!e

ce#halo!#orin! 8@2(11>(12394 Since 1==3( there hae been 11

#ro!#ectie( ran$omie$ trial! /ith #r o #er !t"$y $e!ign(

#artici#ant!( an$ o"tcome mea!"re! that eal"ate$ the "!e o

#ro#hylactic antibiotic! in !eere A' 812>94 +rom thi! meta:

analy!i!( the n"mber nee$e$ to treat /a! 1(2= or one #atient to

beneit4 ;t remain! "ncertain i a !"bgro"# o #atient! /ith !eere

A' 8!"ch a! eDten!ie necro!i! /ith organ ail"re9 may beneit

r om antibiotic!( b"t large !t"$ie! reF"ire$ to $etermine /hether

any beneit eDi!t! /ill be $iic"lt to #erorm4 -a!e$ on the c"rrent

liter : at"re( "!e o #ro#hylactic antibiotic! to #reent inection in

#atient! /ith !terile necro!i! 8een #re$icte$ a! haing !eere

$i!ea!e9 i! not r ecommen$e$4

'reention o "ngal inection! in the!e #atient! i! al!o not

recommen$e$4 Altho"gh it /a! !"gge!te$ that "ngal in ection

may be a more common ca"!e o mortality in A'( "rther

!t"$y ha! not conirme$ thi! in$ing 812?94 There i! one!"cce!!"l ran$omie$ controlle$( clinical trial that "!e$

!electie $econtamination o the bo/el( targeting both

bacteria an$ "ngi( in or$er to #reent inecte$ necro!i!

812594 -eca"!e o the $ecrea!e$ morbi$ity an$ mortality in

thi! trial in #atient! /ith !eere A' /ho ha$ "n$ergone

!electie $econtamina: tion( "rther !t"$y in thi! area i!

nee$e$4 +inally( #r obiotic! !ho"l$ not be gien in !eere

A'4 Altho"gh earlier trial! !"gge!te$ a beneit( a ery /ell:

con$"cte$( ran$omie$ con: trolle$ clinical trial

$emon!trate$ increa!e$ mortal ity 812=94 Thi! lacB o beneit

ha! al!o been !ho/n in a recent meta: analy!i! 813094

OL


13/21

Infecte# necrosis

Rather than #reenting inection( the role o antibiotic! in

#atient! /ith necrotiing A' i! no/ to treat e!tabli!he$ inecte$

necr o: !i!4 The conce#t that inecte$ #ancreatic necro!i! reF"ire!

#r om#t !"rgical $ebri$ement ha! al!o been challenge$ by

m"lti#le r e #or t! an$ ca!e !erie! !ho/ing that antibiotic! alone

can lea$ to r e!ol": tion o inection an$( in !elect #atient!(

aoi$ !"rgery altogether 81311394 Garg et al. 8139 re#orte$

?650 #atient! /ith inecte$ necro!i! oer a 10:year #erio$

/ho /ere !"cce!!"lly tr eate$ con!eratiely /ith antibiotic!

alone 81394 The mortality in the con!eratie gro"# /a! 23

a! com#are$ /ith @ in the !"r gi: cal gro"#4 The !ame gro"#

#"bli!he$ a meta:analy!i! o 5 !t"$ie! inoling 0= #atient!

/ith inecte$ necro!i! o /hom 32 /ere !"cce!!"lly treate$

/ith antibiotic! alone 813@94 Oerall( > o the #atient! /ith

inecte$ necro!i! in thi! meta:analy!i! co"l$ be manage$ by

con!eratie antibiotic treatment /ith 12 mor : tality( an$

only 2> "n$er/ent !"rgery4 Th"!( a !elect gro"# o relatiely

!table #atient! /ith inecte$ #ancreatic necro!i! co"l$ be

manage$ by antibiotic! alone /itho"t reF"iring #er c"tane:o"! $rainage4 *o/eer( it !ho"l$ be ca"tione$ that the!e

#atient! reF"ire clo!e !"#eri!ion an$ #erc"taneo"! or

en$o!co#ic or necro!ectomy !ho"l$ be con!i$ere$ i the #atient

ail! to im #r oe or $eteriorate! clinically4

T*E ROLE O+ CT

+NA

The techniF"e o com#"te$ tomogra#hy g"i$e$ ine nee$le

a!#iration 8CT +NA9 ha! #roen to be !ae( eectie( an$

Pancreatic necrosis: suspected of infection

acc"rate in $i!ting"i!hing inecte$ an$ !terile necro!i!

8@3(13>94 A! #atient! /ith inecte$ necro!i! an$ !terile necro!i!

may a##ear !imilar /ith le"Bocyto!i!( eer( an$ organ ail"re

813?9( it i! im#o!!ible to !e#arate the!e entitie! /itho"t

nee$le a!#iration4 *i!torically( the "!e o antibiotic! i! be!t

e!tabli!he$ in clinically #roen #ancreatic or eDtra #ancr e:

atic inection( an$ thereore CT +NA !ho"l$ be con!i$er e$

/hen an inection i! !"!#ecte$4 An imme$iate reie/ o the

Gram !tain /ill oten e!tabli!h a $iagno!i!4 *o/eer( it may be

#r"$ent to begin antibiotic! /hile a/aiting microbiologic

conirmation4 ; c"lt"re re#ort! are negatie( the antibiotic!

can be $i!contin"e$4

There i! !ome controer!y a! to /hether a CT +NA i! nece!:

!ary in all #atient! 8=igure "94 ;n many #atient!( the CT +NA

/o"l$ not inl"ence the management 813594 ;ncrea!e$ "!e o

con!eratie management an$ minimally ina!ie $rainage

hae $ecrea!e$ the "!e o +NA or the $iagno!i! o inecte$

necro!i! 8@94 &any #atient! /ith !terile or inecte$ necro!i!

either im#roe F"icBly or become "n!table( an$ $eci!ion! on

interention ia a minimally ina!ie ro"te /ill not be inl"ence$ by the re!"lt! o the a!#iration4 A con!en!"! conerence con:

cl"$e$ that +NA !ho"l$ only be "!e$ in !elect !it"ation! /here

there i! no clinical re!#on!e to antibiotic!( !"ch a! /hen a "ngal

inection i! !"!#ecte$ 8@94

N


14/21

!eem! im#eratie4 The long:hel$ a!!"m#tion that the inlame$

#ancrea! reF"ire! #rolonge$ re!t by a!ting $oe! not a##ear to

be !"##orte$ by laboratory an$ clinical ob!eration 813=94

Clini: cal an$ eD#erimental !t"$ie! !ho/e$ that bo/el re!t i!

a!!ociate$ /ith inte!tinal m"co!al atro#hy an$ increa!e$

inectio"! com#li: cation! beca"!e o bacterial tran!location

rom the g"t4 &"lti#le !t"$ie! hae !ho/n that #atient!

#roi$e$ oral ee$ing early in the co"r!e o A' hae a !horter

ho!#ital !tay( $ecrea!e$ inec: tio"! com#lication!( $ecrea!e$

morbi$ity( an$ $ecrea!e$ mortal: ity 811?(101394

;n mil$ A'( oral intaBe i! "!"ally re!tore$ F"icBly an$ no

n"tr i: tional interention i! nee$e$4 Altho"gh the timing o

reee$ing remain! controer!ial( recent !t"$ie! hae !ho/n that

imme$iate oral ee$ing in #atient! /ith mil$ A' a##ear! !ae

813=94 ;n a$$i: tion( a lo/:at !oli$ $iet ha! been !ho/n to be

!ae com#are$ /ith clear liF"i$!( #roi$ing more calorie!

8194 Similarly( in other ran$omie$ trial!( oral ee$ing /ith a

!ot $iet ha! been o"n$ to be !ae com#are$ /ith clear liF"i$!

an$ it !horten! the ho!#ital !tay 81@(1>94 Early reee$ing al!o

a##ear! to re!"lt in a !horter ho!#ital !tay4 -a!e$ on the!e!t"$ie!( oral ee$ing! intro$"ce$ in mil$ A' $o not nee$ to

begin /ith clear liF"i$! an$ increa!e in a !te#/i!e manner( b"t

may begin a! a lo/:re!i$"e( lo/:at( !ot $iet /hen the #atient

a##ear! to be im#r oing4

Total #arenteral n"trition !ho"l$ be aoi$e$ in #atient! /ith

mil$ an$ !eere A'4 There hae been m"lti#le ran$omie$

trial! !ho/ing that total #arenteral n"trition i! a!!ociate$ /ith

inectio"! an$ other line:relate$ com#lication! 8@394 A! enteral

ee$ing main: tain! the g"t m"co!al barrier( #reent!

$i!r"#tion( an$ #r eent! the tran!location o bacteria that !ee$

#ancreatic necro!i!( enteral n"trition may #reent inecte$

necro!i! 812(1394 A recent meta: analy!i! $e!cribing 5

ran$omie$ controlle$ clinical trial! inol: ing 351 #atient!

o"n$ a $ecrea!e in inectio"! com #lication!( organ ail"re(

an$ mortality in #atient! /ith !eere A' /ho /ere #roi$e$

enteral n"trition a! com#are$ /ith total #arenteral n"tr i: tion

81394 Altho"gh "rther !t"$y i! nee$e$( contin"o"! in"!ion i!

#reerre$ oer cyclic or bol"! a$mini!tration4

Altho"gh the "!e o a na!o7e7"nal ro"te ha! been tra$itionally

#reerre$ to aoi$ the ga!tric #ha!e o !tim"lation( na!oga!tric

enteral n"trition a##ear! a! !ae4 A !y!tematic reie/

$e!crib: ing =2 #atient! rom !t"$ie! on na!oga!tric t"be

ee$ing o"n$ that na!oga!tric ee$ing /a! !ae an$ /ell

tolerate$ in #atient! /ith #re$icte$ !eere A' 811?94 There hae

been !ome re#ort! o na!oga!tric ee$ing !lightly increa!ing theri!B o a!#iration4 +or thi! rea!on( #atient! /ith A' "n$ergoing

enteral n"trition !ho"l$ be #lace$ in a more "#right #o!ition

an$ be #lace$ on a!#iration #reca"tion!4 Altho"gh "rther

!t"$y i! nee$e$( eal"ating or Ire!i$"al!(J retaine$ ol"me in

the !tomach( i! not liBely to be hel #: "l4 Com#are$ /ith

na!o7e7"nal ee$ing( na!oga!tric t"be #lace: ment i! ar ea!ier(

/hich i! im#ortant in #atient! /ith A'( e!#ecially in the

inten!ie care !etting4 Na!o7e7"nal t"be #lacement r eF"ir e!

interentional ra$iology or en$o!co#y an$ th"! can be

eD#en!ie4 +or the!e rea!on!( na!oga!tric t"be ee$ing !ho"l$ be

#r e er r e$ 81?94 A large m"lticenter trial !#on!ore$ by the

National ;n!ti: t"te! o *ealth 8N;*9 i! c"rrently being

#erorme$ to ine!tigate /hether na!oga!tric or na!o7e7"nal

ee$ing! are #reerre$ in the!e

#atient! beca"!e o !igniicant eD#erimental an$ !ome

h"man ei$ence o !"#eriority o $i!tal 7e7"nal ee$ing in A'4

T*E ROLE O+ S


15/21

;n the ma7ority o #atient! /ith gall!tone #ancreatiti!(

the common bile $"ct !tone #a!!e! to the $"o$en"m4 Ro"tine

ERC' i! not a##ro#riate "nle!! there i! a high !"!#icion o a

#er !i!: tent common bile $"ct !tone( manie!te$ by an eleation

in the bilir"bin 81@194 'atient! /ith mil$ A'( /ith normal

bilir "bin( can "n$ergo la#ro!co#ic cholecy!tectomy /ith

intrao#eratie cholangiogra#hy( an$ any remaining bile $"ct

!tone! can be $ealt /ith by #o!to#eratie or intrao#eratie

ERC'4 ;n #atient! /ith lo/ to mo$erate ri!B( &RC' or E94

&;N;&ALLY ;NAS;E &ANAGE&ENT O+

'ANCREAT;C NECROS;S

&inimally ina!ie a##roache! to #ancreatic necr o!ectomy

incl"$ing la#ro!co#ic !"rgery either rom an anterior or r etr o:

#eritoneal a##roach( #erc"taneo"!( ra$iologic catheter $rain:

age or $ebri$ement( i$eo:a!!i!te$ or !mall inci!ion:ba!e$ let

retro#eritoneal $ebri$ement( an$ en$o!co#y are increa!ingly

becoming the !tan$ar$ o care4 'erc"taneo"! $rainage /itho"t

necro!ectomy may be the mo!t reF"ently "!e$ minimally ina:

!ie metho$ or managing l"i$ collection! com#licating necr o:

tiing A' 8@(>5(15(1@21@?94 The oerall !"cce!! a##ear! to be

U@0 in aoi$ing o#en !"rgery4 ;n a$$ition( en$o!co#ic $rainage

o necrotic collection! an$6or $irect en$o!co#ic necr o!ectomyha! been re#orte$ in !eeral large !erie! to be eF"ally !"cce!!"l

8@3(@(1@@94 Sometime! the!e mo$alitie! can be combine$ at the

!ame time or !eF"entially( or eDam#le( combine$ #er c"taneo"!

an$ en$o!co#ic metho$!4 Recently( a /ell:$e!igne$ !t"$y r om

the Netherlan$! "!ing a !te#:"# a##roach 8#erc"taneo"! catheter

$rainage ollo/e$ by i$eo:a!!i!te$ retro#eritoneal $ebr i$ement9

8>5(1@>9 $emon!trate$ the !"#eriority o the !te#:"# a ##r oach

a! relecte$ by lo/er morbi$ity 8le!! m"lti#le organ ail"re an$

!"rgical com#lication!9 an$ lo/er co!t! com#are$ /ith o#en

!"rgical necro!ectomy4

Altho"gh the!e g"i$eline! cannot $i!c"!! in $etail the ario"!

metho$! o $ebri$ement( or the com#aratie eectiene!! o

each( beca"!e o limitation! in aailable $ata an$ the oc"! o thi!

reie/( !eeral generaliation! are im#ortant4 Regar$le!! o the

metho$ em#loye$( minimally ina!ie a##roache! reF"ire the

#ancr eatic necro!i! to become organie$ 8@(>5(1@1@?94

.herea! early in the co"r!e o the $i!ea!e 8/ithin the ir!t ?

10 $ay!9 #ancr eatic necro!i! i! a $i"!e !oli$ an$6or !emi!oli$

inlammatory ma!!( ater U /eeB! a ibro"! /all $eelo#!

aro"n$ the necro!i! that maBe! remoal more amenable to o#en

an$ la#ro!co#ic !"rgery( #erc"taneo"! ra$iologic catheter

$rainage( an$6or en$o!co#ic $rainage4

C"rrently( a m"lti$i!ci#linary con!en!"! aor! minimally

ina: !ie metho$! oer o#en !"rgery or the management o

#ancr eatic necro!i! 8@94 A recent ran$omie$ controlle$ trialclearly $em: on!trate$ the !"#eriority o en$o!co#ic $ebri$ement

oer !"rgery 81@94 Altho"gh a$ance! in !"rgical( ra$iologic(

an$ en$o!co#ic techniF"e! eDi!t an$ are in $eelo#ment( it m"!t

be !tre!!e$ that many #atient! /ith !terile #ancreatic necro!i!(

an$ !elect #atient! /ith inecte$ necro!i!( clinically im#roe to

a #oint /here no interention i! nece!!ary 8@(1394 The

management o #atient! /ith #ancreatic necro!i! !ho"l$ be

in$ii$"alie$( reF"iring con: !i$eration o all the aailable $ata

8clinical( ra$iologic( la borator y9 an$ "!ing aailable eD#erti!e4

Early reerral to a center o eDcel: lence i! o #aramo"nt

im#ortance( a! $elaying interention /ith


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maDimal !"##ortie care an$ "!ing a minimally ina!ie

a ##r oach hae both been !ho/n to re$"ce morbi$ity an$

mortality4

C33%323304@4 -ra$ley EL4 A clinically ba!e$ cla!!iication !y!tem o ac"te #ancr eatiti!4

Arch S"rg 1==3125%@5>=04

>4 -anB! 'A( -ollen TL( )ereni! C et al. Cla!!iication o ac"te #ancreati:ti!P2012% rei!ion o Atlanta cla!!iication an$ $einition! by

inter national con!en!"!4 G"t 2013>2%102114?4 -"!F"et! ,( +abregat ,( 'elae N et al. +actor! inl"encing mortality in

#atient! "n$ergoing !"rgery or ac"te #ancreatiti!% im#ortance o #er i: #ancreatic ti!!"e an$ l"i$ inection4 'ancrea! 20132%25@=24

54 &ar!hall ,C( CooB ),( Chri!to" N et al. &"lti#le organ $y! "nction!core% a reliable $e!cri#tor o com#leD clinical o"tcome4 Crit Care

&e$

1==@23%1>35@24

=4 .all ;( -a$alo N( -ara$arian R et al. )ecrea!e$ morbi$ity an$ mortality

in #atient! /ith ac"te #ancreatiti! relate$ to aggre!!ie intraeno"!

hy$ration4 'ancrea! 20110%@?@04104 Gar$ner T-( ege SS( 'ear!on RQ et al. +l"i$ re!"!citation in

ac"te #ancreatiti!4 Clin Ga!troenterol *e#atol 2005>%10?0>4114 G"yatt G*( ODman A)( i!t GE et al. GRA)E% an emerging con!en!"! on

rat: ing F"ality o ei$ence an$ !trength o recommen$ation!4 -&,200533>%=2>4

124 Claien 'A( Robert ,( &eyer ' et al. Ac"te #ancreatiti! an$nor moamyla!emia4

Not an "ncommon combination4 Ann S"rg 1=5=210%>1204

134 .in!let &( *all C( Lon$on N,&4 Relation o $iagno!tic !er"m amyla!e

leel! to aetiology an$ !eerity o ac"te #ancreatiti!4 G"t 1==233%=52

>4

14 &alBa )( Ro!a:*eo$e ;4 'o!itie an$ etiological $iagno!i! o ac"te #ancreatiti!4 Ga!troenterol Clin -iol 20012@%1S1@31S>54

1@4 4

1?4 Shah A&( E$$i R( Qothari ST et al. Ac"te #ancreatiti! /ith normal

!er "m li#a!e% a ca!e !erie!4 ,O' 201011%3>=?24154 Qiriyama( Gabata T( TaBa$a T et al. Ne/ $iagno!tic criteria o

ac"te #ancreatiti!4 , *e#atobiliary 'ancreat Sci 20101?%23>41=4 Li##il G( alentino &( Cerellin G4 Laboratory $iagno!i! o ac"te

#ancr ea: titi!% in !earch o the *oly Grail4 Crit Re Clin Lab Sci2012=%15314

204 -althaar E,4 Ac"te #ancreatiti!% a!!e!!ment o !eerity /ith clinical an$

CT

eal"ation4 Ra$iology 2002223%>03134

214 AranitaBi! &( )elhaye &( &aertelaere ) et al. Com#"te$ tomogr a #hyan$ &R; in the a!!e!!ment o ac"te #ancreatiti!4 Ga!troenterology 200

12>%?1@234

224 Vaheer A( Singh Q( W"re!hi RO et al. The rei!e$ Atlantacla!!iication or ac"te #ancreatiti!% "#$ate! in imaging terminology an$g"i$eline!4 Ab$om ;maging 201335%12@3>4

234 -ollen TL( Singh Q( &a"rer R et al. Com#aratie eal"ation o

the mo$iie$ CT !eerity in$eD an$ CT !eerity in$eD in a!!e!!ing!eerity o ac"te #ancreatiti!4 A,R Am , Roentgenol20111=?%35>=24

24 Stimac )( &iletic )( Ra$ic & et al. The role o non enhance$

mangetic re!onance imaging in the early a!!e!!ment o ac"te #ancreatiti!4 Am , Ga!troenterol 200?102%==?1004


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@4 LanBi!ch 'G( A!!m"! C( LehnicB ) et al. Ac"te #ancreatiti!% $oe! gen$er

matter )ig )i! Sci 2001>%2?04

>4 G"llo ;( &igliori &( Olah A et al. Ac"te #ancreatiti! in ie E"r o #eanco"ntrie!% etiology an$ mortality4 'ancrea! 20022%223?4

?4 Lo/enel! A-( &ai!onne"e '( S"llian T4 The changing character o ac"te #ancreatiti!% e#i$emiology( etiology( an$ #rogno!i!4 C"rr Ga!troenterol Re#

200=11%=?1034

54 ,ohn!on C( LXy '4 )etection o gall!tone! in ac"te #ancreatiti!% /hen an$ ho/'ancreatology 201010%2?324

=4 &orea" ,A( Vin!mei!ter AR( &elton L, et al. Gall!tone #ancreatiti! an$ the eecto cholecy!tectomy4 &ayo Clin 'roc >3>>%1=554

04 Ya$a )( OMConnell &( 'a#achri!to" G;4 Nat"ral hi!tory ollo/ing the ir!t attacB

o ac"te #ancreatiti!4 Am , Ga!troenterol 201210?%10=>1034314 Ammann R.4 The nat"ral hi!tory o alcoholic chronic #ancreatiti!4 ;nter n&e$ 20010%3>5?@4

24 Steinberg .( Tenner S4 &e$ical #rogre!!% ac"te #ancreatiti!4 Ne/ Engl , &e$

1==330%11=52104

34 Rebo"r! ( "llierme &'( *entic O et al. SmoBing an$ the co"r!e o

rec"rrent ac"te an$ chronic alcoholic #ancreatiti!% a $o!e:$e#en$ent

relation!hi#4 'ancrea! 20121%121=24

34 .hitcomb )C4 Genetic #olymor#hi!m! in alcoholic #ancreatiti!4 )ig )i!

Sci 200@23%2?@4

3@4 -a$alo N( -ara$arian R( ;!/ara Q et al. )r"g in$"ce$ ac"te #ancr eatiti!%an ei$ence ba!e$ a##roach4 Clin Ga!troenterol *e#atol 200?101%@?>4

>4 +ort!on &R( +reeman SN( .eb!ter ')4 Clinical a!!e!!ment o hy #erli #i$: meic #ancreatiti!4 Am , Ga!troenterol 1==@=0%213=4

3?4 'arenti )&( Steinberg .( Qang '4 ;nectio"! ca"!e! o ac"te #ancr eatiti!4'ancrea! 1==>13%3@>?14

54 +armer RG( .inBelman E;( -ro/n *- et al. *y#erli#o#roteinemia an$

#ancreatiti!4 Am , &e$ 1=?3@%1>1@4

=4 To!Be! ''4 *y#erli#i$mic #ancreatiti!4 Ga!troenterol Clin North Am

1==01=%?53=14

04 Ya$a )( 'itch"moni CS4 ;!!"e! in hy#erli#i$emic #ancreatiti!4 , ClinGa!troenterol 20033>%@>24

14 Sim#!on .+( A$am! )-( &etcal ,S et al. Non"nctioning #ancr eaticne"roen$ocrine t"mor! #re!enting a! #ancreatiti!% re#ort o o"r ca!e!4

'ancrea! 1=553%223314

24 Qohler *( LanBi!ch 'G4 Ac"te #ancreatiti! an$ hy#eramyla!aemia in #ancreatic carcinoma4 'ancrea! 1=5?2%11?=4

34 Robert!on ,+( ;mrie C.4 Ac"te #ancreatiti! a!!ociate$ /ith carcinoma

o the am#"lla o ater4 -r , S"rg 1=5??%3=@?4

4 -anB S( ;n$aram A4 Ca"!e! o ac"te an$ rec"rrent #ancreatiti!4

Clinical con!i$eration! an$ cl"e! to $iagno!i!4 Ga!troenterol Clin North

Am

1===25%@?15=( iii4

@4 -anB! 'A4 E#i$emiology( nat"ral hi!tory( an$ #re$ictor! o $i!ea!e

o"tcome in ac"te an$ chronic #ancreatiti!4 Ga!trointe!t En$o!c2002@>%S22>304

>4 Tan$on &( To#aian &4 En$o!co#ic "ltra!o"n$ in i$io#athic ac"te #ancreatiti!4 Am , Ga!troenterol 2001=>%?0@=4

?4 Al:*a$$a$ &( .allace &-4 )iagno!tic a##roach to #atient! /ith ac"te

i$io#athic #ancreatiti!( /hat !ho"l$ be $one .orl$ , Ga!tr oenter ol20051%100?104

54 )i&agno &,( )imagno E'4 'ancrea! $ii!"m $oe! not ca"!e #ancr eatiti!(

b"t a!!ociate! /ith C+TR m"tation!4 Am , Ga!troenterol 201210?%315

204

=4 Steinberg .&( Chari ST( +or!marB CE et al. Controer!ie! in clinical

#ancreatology% management o ac"te i$io#athic rec"rrent #ancr eatiti!4 'ancrea! 20032?%1031?4

@04 -a$alo N( Tenner S( -aillie ,4 'reention an$ treatment o #o!t:ER C'

#ancreatiti!4 ,O' 200=10%55=?4

@14 Cote GA( ;m#eriale T+( Schmi$t SE et al. Similar eicacie! o biliary( /ithor /itho"t #ancreatic( !#hincterotomy in treatment o i$io#athicr ec"rr ent ac"te #ancreatiti!4 Ga!troenterology 2012>9%1@02=4

@24 Tenner S4 ;nitial management o ac"te #ancreatiti!% critical $eci!ion!$"r ing the ir!t ?2 ho"r!4 Am , Ga!troenterol 200==%25==4

@34 -anB! 'A( +reeman &L4 'ractice g"i$eline! in ac"te #ancreatiti!4 Am

, Ga!troenterol 200>101%23?=004

@4 +reeman &+( .erner ,( an Santoort *C et al. ;nterention! ornecroti: ing #ancreatiti!4 S"mmary o a m"lti:$i!ci#linary con!en!"!con er ence4 'ancrea! 20125%11?>=4

@@4 'ere A( .hang EE( -rooB! )C et al. ;! !eerity o necrotiing

#ancr eatiti! increa!e$ in eDten$ing necro!i! an$ inecte$ necro!i!'ancr ea!

20022@%22=334

@>4 -aBBer O,( an Santoort *( -e!!elinB &G et al. EDtra#ancreatic necr o!i!/itho"t #ancreatic #arenchymal necro!i!% a !e#arate entity in necroti!ing #ancreatiti! G"t 201215%13=4

OL


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@?4 Ran!on ,*( 'a!ternacB -S4 Stati!tical metho$! or F"antiying the

!eer ity o clinical ac"te #ancreatiti!4 , S"rg Re! 1=??22%?==14

@54 Qna"! .A( )ra#er EA( .agner )' et al. A'AC*E ;;% a !eerity o

$i!ea!e cla!!iication !y!tem4 Crit Care &e$ 1=5@13%5152=4

@=4 ." -524

>34 -ro/n A( Ora ,( -anB! 'A4 *emoconcentration i! an early marBer or organ ail"re an$ necrotiing #ancreatiti!4 'ancrea! 200020%3>? ?24

>4 LanBi!ch 'G( &ahlBe R( -l"m T et al. *emoconcentration% an early

marBer o !eere an$6or necrotiing #ancreatiti! A critical

a ##r ai!al4 Am , Ga!troenterol 2001=>%2051@4>@4 +ro!!ar$ ,L( *a$eng"e A( 'a!tor C&4 Ne/ !er"m marBer! or the

$etection o !eere ac"te #ancreatiti! in h"man!4 Am , Re!#ir Crit Care

&e$ 20011>%1>2?04

>>4 'a#achri!to" G;( .hitcomb )C4 ;nlammatory marBer! o $i!ea!e!eer : ity in ac"te #ancreatiti!4 Clin Lab &e$ 200@2@%1?3?4

>?4 -althaar E,( Robin!on )L( &egibo/ A, et al. Ac"te #ancreatiti!% al"e o

CT in e!tabli!hing #rogno!i!4 Ra$iology 1==01?%331>4

>54 an Santoort *C( -e!!elinB &G( -aBBer O, et al. A !te#:"#

a ##r oach or o#en necro!ectomy or necrotiing #ancreatiti!4 Ne/Engl , &e$

20133>2%1=1@024

>=4 Tran ))( C"e!ta &A4 Eal"ation o !eerity in #atient! /ith ac"te

#an: creatiti!4 Am , Ga!troenterol 1==25?%>054?04 &oi$i R( )" &)( .igmore S, et al. A!!ociation bet/een early

!y!temic inlammatory re!#on!e( !eerity o m"ltiorgan $y!"nction an$

$eath in ac"te #ancreatiti!4 -r , S"rg 200>=3%?354

?14 -"ter A( ;mrie C.( Carter CR et al. )ynamic nat"re o early or gan$y!"nction $etermine! o"tcome in ac"te #ancreatiti!4 -r , S"rg

20025=%2=53024

?24 'a#achri!to" G;( &"$$ana ( Ya$a ) et al. ;ncrea!e$ !er"m creatininei! a!!ociate$ /ith #ancreatic necro!i! in ac"te #ancreatiti!4 Am , Ga!tr o:enterol 201010@%1@124

?34 *eller S,( Noor$hoeB E( Tenner S& et al. 'le"ral e"!ion a! a #re$ictor

o !eerity in ac"te #ancreatiti!4 'ancrea! 1==?1@%222@4?4 +"nnell ;C( -ornman 'C( .eaBley S' et al. Obe!ity% an im#ortant

#r og: no!tic actor in ac"te #ancreatiti!4 -r , S"rg 1==350%5>4

?@4 &ann )( *er!hman &,( *ittinger R et al. &"lticentre a"$it o$eath rom ac"te #ancreatiti!4 -r , S"rg 1==51%5=034

?>4 &"tinga &( Ro!enbl"th A( Tenner S& et al. )oe! mortality occ"r early

or late in ac"te #ancreatiti! ;nt , 'ancreatol 200025%=1@4??4 ,ohn!on C)( Ab":*ilal &4 'er!i!tent organ ail"re $"ring the ir!t

/eeB a! a marBer o atal o"tcome in ac"te #ancreatiti!4 G"t

200@3%

1304

?54 Lytra! )( &ane! Q( Trianto#o"lo" C et al. 'er!i!tent early organail"r e% $eining the high ri!B gro"# o #atient! /ith !eere ac"te

#ancr eatiti!4 'ancrea! 20053>%2=@4?=4 Qerner T( ollmar -( &enger &) et al. )eterminant! o #ancreatic

micro: circ"lation in ac"te #ancreatiti! in rat!4 , S"rg Re! 1==>>2%1>@?14

504 -a!!i )( Qollia! N( +ernan$e:$el Ca!tillo C et al. ;m#airment o #ancr e: atic microcirc"lation correlate! /ith the !eerity o ac"teeD#erimental #ancreatiti!4 , Am Coll S"rg 1==1?=%2@?>34

514 ;no"e Q( *irota &( -e##" T et al. Angiogra#hiceat"re! in ac"te

#ancr ea: titi!% the !eerity o ab$ominal e!!el i!chemic change relect!

the !eer ity o ac"te #ancreatiti!4 ,O' 2003%20?134524 -ie '( 'laton A( -ecBer C4 'er"!ion mea!"rement in ac"te

#ancr eatiti! "!ing $ynamic #er"!ion &) CT4 Am , Ra$iol200>15>%1154

534 ." -


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5>4 .arn$or &G( Q"rtman ,T( -artel &, et al. Early l"i$

r e!"!citation re$"ce! morbi$ity among #atient! /ith ac"te #ancreatiti!4 Clin Ga!tr o: enterol *e#atol 2011=%?0@=4

5?4 &ao EW( +ei ,( 'eng Y- et al. Ra#i$ hemo$il"tion i!a!!ociate$ /ith increa!e$ !e#!i! an$ mortality among #atient! /ith !eere ac"te #ancreatiti!4 Chin &e$ , 8Engl92010123%1>3=4

554 $e:&a$aria E( Soler:Sala G( Snche:'aya , et al. ;nl"ence o

l"i$ thera #y on the #rogno!i! o ac"te #ancreatiti!% a #ro!#ectiecohort !t"$y4 Am , Ga!troenterol 201110>%153@04

5=4 Qha7ai &R( Etea$i +( &oharari RS et al. Eect! o normal

!aline !4 lactate$ Ringer M! $"ring renal tran!#lantation4 Renal

+ail 200530%@3@=4=04 Cho YS( Lim *( Qim S*4 Com#ari!on o lactate$ R inger M!

!ol"tion an$

04= !aline in the treatment o rhab$omyoly!i! in$"ce$ by$oDylamine intoDication4 Emerg &e$ , 200?2%2?>504

=14 EcBer/all G( Olin *( An$er!!on - et al. +l"i$ re!"!citation an$

n"tr itional !"##ort $"ring !eere ac"te #ancreatiti! in the #a!t%/hat hae /e lear ne$ an$ ho/ can /e $o better Clin N"tr200>2@%=?@04

=24 Aco!ta ,&( Le$e!ma CL4 Gall!tone migration a! a ca"!e

o ac"te #ancreatiti!4 N Engl , &e$ 1=?2=0%5?4=34 Neo#tolemo! ,'( Lon$on N,( ,ame! ) et al. Controlle$ trail o

"r gent en$o!co#ic retrogra$e cholangio#ancreatogra#hy an$en$o!co#ic !#hinc: terotomy er!"! con!eratie management or

ac"te #ancreatiti! $"e to gall!tone!4 Lancet 1=553%=?=534=4 +an ST( Lai EC( &oB +' et al. Early treatment o ac"te biliary

#ancr eatiti! by en$o!co#ic #a#illotomy4 Ne/ Engl , &e$

1==3325%225324=@4 +ol!ch %23?24=>4 Arg"e$a! &R( )"#ont A.( .ilcoD C&4 .here $o ERC'(

en$o!co #ic "ltra!o"n$( magnetic re!onancecholangio#ancreatogra#hy( an$ intra: o#eratie cholangiogra#hyit in the management o ac"te biliary #ancr ea: titi! A $eci!ionanaly!i! mo$el4 Am , Ga!troenterol 2001=>%25=2=4

=?4 &oretti A( 'a#i C( Aratari A et al. ;! early en$o!co#ic

r etr ogra$e cholangio#ancreatogra#hy "!e"l in the

management o ac"te biliar y #ancreatiti! A meta:analy!i! o

ran$omie$ controlle$ trial!4 )i Lier )i! 20050%3?=5@4

=54 +reeman &L( )iSario ,A( Nel!on )- et al. Ri!B actor! or #o!t:ER C'

#ancreatiti!% a #ro!#ectie( m"lticenter !t"$y4 Ga!trointe!t En$o!c

2001@%2@34

==4 &ehta SN( 'aone E( -arB"n ,S et al. 're$ictor! o #o!t:ERC'

com#lication! in #atient! /ith !"!#ecte$ chole$ocholithia!i!4 En$o!co#y1==530%@?>34

1004 Lella +( -agnolo +( Colombo E et al. A !im#le /ay o aoi$ing #o!t:ER C'

#ancreatiti!4 Ga!trointe!t En$o!c 200@=%5304

1014 Artion EL( SaBai '( C"nha ,E et al. G"i$e/ire cann"lation re$"ce!r i!B o #o!t:ERC' #ancreatiti! an$ acilitate! bile $"ct cann"lation4

Am , Ga!troenterol 200?102%21?@34

1024 &ariani A( Gi"!!ani A( )i Leo & et al. G"i$e/ire biliary cann"lation$oe! not re$"ce #o!t:ERC' #ancreatiti! com#are$ /ith the contra!t in 7ec:tion techniF"e in lo/:ri!B an$ high:ri!B #atient!4 Ga!trointe!t En$o!c

2012?@%33=>4

1034 Che"ng ,( T!oi QQ( W"an .L et al. G"i$e/ire er!"! conentionalcontra!t cann"lation o the common bile $"ct or the #reention o #o!t:ERC' #ancreatiti!% a !y!tematic reie/ an$ meta:analy!i!4 Ga!tr ointe!t

En$o!c 200=?0%1211=4

104 A$ler )G( erma )( *il$en Q et al. )ye:ree /ire:g"i$e$ cann"lation o

the biliary tree $"ring ERC' i! a!!ociate$ /ith high !"cce!! an$ lo/

com#lication rate!% o"tcome! in a !ingle o#erator eD#erience o 522 ca!e!4

, Clin Ga!troenterol 2010%e@?>24

10@4 An$ri"lli A( +orlano R( Na#olitano G et al. 'ancreatic $"ct !tent! in the #ro#hylaDi! o #ancreatic $amage ater en$o!co#ic retrogra$e cholangio: #ancr eatogra #hy% a !y!tematic analy!i! o beneit! an$ a!!ociate$ r i!B!4)ige!tion 200??@%1@>>34

10>4 Ra!h$an A( +ogel EL( &c*enry ,r L et al. ;m#roe$ !tent

char acter i!tic! or #ro#hylaDi! o #o!t:ERC' #ancreatiti!4 ClinGa!troenterol *e #atol2002%322=4

10?4 )a! A( Singh '( SiaB ,r & et al. 'ancreatic:!tent #lacement or

#reention o #o!t:ERC' #ancreatiti!% a co!t eectiene!! analy!i!4Ga!trointe!t En$o!c 200?>@%=>054

1054 +reeman &L4 'ancreatic !tent! or #reention o #o!ten$o!co#ic r etr o:

gra$e cholangio#ancreatogra#hy #ancreatiti!4 Clin Ga!troenterol *e #atol200?@%13@>@4

10=4 Soto"$ehmane!h R( Qhatibian &( Qolah$ooan S et al. ;n$omethacinmay re$"ce the inci$ence an$ !eerity o ac"te #ancreatiti! ater ERC'4Am , Ga!troenterog 200?102%=?5534


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1104 Elm"ner -,( .al7ee AQ( Elta G* et al. A meta:analy!i! o rectal

NSA;)! in the #reention o #o!t:ERC' #ancreatiti!4 G"t 2005@?%12>2

?4

1114 &"rray -( Carter R( ;mrie C et al. )icloenac re$"ce! the inci$ence o

ac"te #ancreatiti! ater en$o!co#ic retrogra$e

cholangio #ancr eatogra #hy4 Ga!troenterology 200312%1?5>=141124 Qho!hbaten &( Qhorram *( &a$a$ L et al. Role o $icloenac in

r e$"cing #o!t:en$o!co#icretrogra$e cholangio#ancreatogra#hy #ancr eatiti!4, Ga!troenterol *e#atol 200523%11>4

1134 Elm"ner -,( Scheiman ,&( Lehman GA et al. A ran$omie$ trial o

rectal in$omethacin to #reent #o!t:ERC' #ancreatiti!4 N Engl ,&e$20123>>%11224

114 -aril N-( Rall! '.( .ren S& et al. )oe! an inecte$ #eri#ancreatic

l"i$ collection or ab!ce!! man$ate o#eration Ann S"rg 2000231%3>1

?4

11@4 -eger *G( Ra" -( ;!enmann R4 Nat"ral hi!tory o necrotiing #ancr eatiti!4'ancreatology 20033%=31014

11>4 -eger *G( -ittner R( -locB S et al. -acterial contamination o

#ancr eatic necro!i!% a #er!#ectie clinical !t"$y4 Ga!troenterology1=5>=1%3354

11?4 'etro &S( Q"Bo!h &( Emelyano N4 A ran$omie$ controlle$

tr ial o enteral er!"! #arenteral ee$ing in #atient! /ith #re$icte$

!eer e ac"te #ancreatiti! !ho/! a !igniicant re$"ction in mortality an$in inecte$ #ancreatic com#lication! /ith total enteral n"trition4 )ig

S"r g200>23%33>@41154 -e!!elinB &G( -er/er T,( ShoenmaecBer! E, et al. Timing o !"r gical

interention in necrotiing #ancreatiti!4 Arch S"rg 200?12%11= 2014

11=4 'e$eroli '( -a!!i C( e!ontini S et al. A ran$omie$ m"lticenter

clinical trial o antibiotic #ro#hylaDi! o !e#tic com#lication! in ac"te

necrotiing #ancreatiti! /ith imi#enem4 S"rg Gynecol Ob!tet1==31?>%5034

1204 Saino ( Qem##ainem E( '"olaBBainen ' et al. Early antibiotic

tr eatment in ac"te necrotiing #ancreatiti!4 Lancet 1==@3>%>>3?41214 )ellinger E'( Tella$o ,&( Soto NE et al. Early antibiotic treatment or

!eere ac"te necrotiing #ancreatiti!% a ran$omie$( $o"ble blin$( #lacebocontrolle$ !t"$y4 Ann S"rg 200?2@%>?534

1224 ;!enmann R( R"ni &( Qron & et al. 'ro#hylactic antibiotic tr eatment

in #atient! /ith #re$icte$ !eere ac"te #ancreatiti!% a #lacebo:contr olle$( $o"ble:blin$ trial4 Ga!troenterology 20012>%==?1004

1234 illatoro E( -a!!i C( Larin &4 Antibiotic thera#y or #ro#hylaDi!again!t inection o #ancreatic necro!i! in ac"te #ancreatiti!4 Cochrane)ataba!e Sy!t Re%C)002=14

124 )e rie! A( -e!!elinB &G( -"!Ben! E et al. Ran$omie$ controlle$ tr ial!

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bet/een metho$ologic F"ality an$ o"tcome4 'ancreatology 200??%@3154

12@4 ,ari NS( &ahi$ SS( ;$!tein SR et al. Antibiotic #ro#hylaDi! i! not

#r otec: tie in !eere ac"te #ancreatiti!% a !y!temic reie/ an$ meta:analy!i!4 Am , S"rg 200=1=?%50>134

12>4 ,iang Q( *"ang .( Yang N et al. 're!ent an$ "t"re o #r o #hylacticantibiotic! or !eere ac"te #ancreatiti!4 .orl$ , Ga!troenterol

201215%

2?=54

12?4 TriB"$anathan G( NAaneethan %1155=24

1254 L"iten E,( *o# .C( Lange ,+ et al. Controlle$ clinical trial o !electie$econtamination or the treatment o !eere ac"te #ancreatiti!4 Ann

S"r g1==@222%@?>@4

12=4 -e!!elinB &G( an Santoort *C( -"!Ben! E et al. 'robiotic

#r o #hylaDi! in #re$icte$ !eere ac"te #ancreatiti!% a ran$omi!e$($o"ble:blin$( #lacebo:controlle$ trial4 Lancet 20053?1%>@1=4

1304 S"n S( Yang Q( *e et al. LangenbecB! 'robiotic! in #atient! /ith

!eer e ac"te #ancreatiti!% a meta:analy!i!4 Arch S"rg 200=3=%1?1?41314 *art/ig .( &aB!an S&( +oitiB T et al. Re$"ction in mortality

/ith $elaye$ !"rgical thera#y o !eere #ancreatiti!4 , Ga!trointe!tS"r g2002>%51?4

1324 )"bner *( Steinberg .( *ill & et al. ;necte$ #ancreatic necro!i! an$ #eri#ancreatic l"i$ collection!% !eren$i#ito"! re!#on!e to antibiotic!

an$ me$ical thera#y in three #atient!4 'ancrea! 122=5%1==>4

1334 R"ni &( Niebel .( Goebell * et al. Seere ac"te #ancreatiti!% non!"r gical treatment o inecte$ necro!i!4 'ancrea! 200@30%1=@=4

134 Garg 'Q( Sharma &( &a$an Q et al. 'rimary con!eratie

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21/21

3@4 &o"li '( i!hn"bhatla S( Garg 'Q4 Eicacy o con!eratie tr eatment(

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3?4 Tenner S&( +eng S( Noer$ooB S et al. The relation!hi# o organ ail"re to #ancreatic necro!i!4 Ga!troenterology 1==?113%5===034

354 'a##a! T4 ;! CT g"i$e$ ine nee$le a!#iration hel#"l in #atient! /ithinecte$ necro!i!4 Am , Ga!troenterol 200@100%23?14

3=4 EcBer/all GE( Ting!te$t --( -ergena"n 'E et al. ;mme$iate oral ee$ing in #atient! /ith ac"te #ancreatiti! i! !ae an$ may accelerate r ecoer y::a

ran$omie$ clinical !t"$y4 Clin N"tr 200?2>%?@5>3404 Lo"ie -E( No!e/orthy T( *ailey ) et al. 200 &acLean:&"eller 'r ie enteral or

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14 Ca!a! &( &ora ,( +ort E et al. Total enteral n"trition !4 total #ar enteraln"trition in #atient! /ith !eere ac"te #ancreatiti!4 Re E!# Enerm )ig200?==%2>=4

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0>134

34 Yi +( Ge L( Vhao , et al. &eta:analy!i!% total #arenteral n"trition er !"! totalenteral n"trition in #re$icte$ !eere ac"te #ancreatiti!4 ;ntern &e$2012@1%@23304

4 ,acob!on -C( an$r liet &-( *"ghe! &) et al. A #ro!#ectie( ran$o: mie$trial o clear liF"i$! er!"! lo/:at !oli$ $iet a! the initial meal in mil$ ac"te

#ancreatiti!4 Clin Ga!troenterol *e#atol 200?@%=>@14@4 Sathiara7 E( &"rthy S( &an!ar$ &, et al. Clinical trial oral ee$ing /ith a !ot

$iet com#are$ /ith clear liF"i$ $iet a! initial meal in mil$ ac"te #ancreatiti!4Aliment 'harmacol 200525%???514

1>4 &orae! ,&( +elga GE( Chebli LA et al. A "ll !oli$ $iet a! the initial meal

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Clin Ga!troenterol 2010%@1?224

1?4 Singh N( Sharma -( Sharma & et al. Eal"ation o early enteral

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#ancr eatiti!4 A non:ineriority ran$omie$ controlle$ trial4 'ancrea!20121%

1@3 =4

154 Lar!on S)( Neal!on .*( Eer! -&4 &anagement o gall!tone #ancr eatiti!4A$ S"rg 200>0%2>@54

1=4 4

1@04 Trna ,( ege SS( 'ribram!Ba et al. LacB o !igniicant lier enyme

eleation an$ gall!tone! an$6or !l"$ge on "ltra!o"n$ on $ay 1 o ac"te

#ancreatiti! i! a!!ociate$ /ith rec"rrence ater cholecy!tectomy% a #o#"la:tion:ba!e$ !t"$y4 S"rgery 21021@1%1==20@4

1@14 Ay"b Q( ;ma$a R( Slain ,4 ERC' in gall!tone a!!ociate$ ac"te #ancr eatiti!4

Cochrane )ataba!e Sy!t Re 200%C)003>304

1@24 A$ler )G( Chari ST( )ahl T, et al. Con!eratie management oin ecte$ necro!i! com#licating !eere ac"te #ancreatiti!4 Am ,Ga!tr oenter ol2003=5%=51034

1@34 an -aal &C( an Santoort *C( -ollen TL et al. Sy!tematic reie/

o #erc"taneo"! catheter $rainage a! #rimary treatment ornecrotiing #ancreatiti!4 -r , S"rg 2011=5%152?4

1@4 -aBBer O,( an Santoort *C( an -r"n!chott S et al. En$o!co#ic

tran!: ga!tric ! !"rgical necro!ectomy or inecte$ necrotiing #ancr eatiti!a ran$omie$ trial4 ,A&A 201230?%10@3>14

1@@4 ege SS( -aron T*4 &anagement o #ancreatic necro!i! in !eere

ac"te #ancreatiti!4 Clin Ga!troenterol *e#atol 200==%25==4

1@>4 an Santoort *C( -aBBer O,( -ollen T et al. A con!eratie an$ mini:mally ina!ie a##roach to necrotiing #ancreatiti! im#roe! the o"tcome4Ga!troenterology 201111%12@>34

1@?4 *ong S( Wi/en -( Ying , et al. -o$y ma!! in$eD an$ the ri!B an$ #r og:

no!i! o ac"te #ancreatiti!% a meta:analy!i!4 E"r , Ga!troenterol

*e #atol201112%13>34

(613610363) ACG Guideline AcutePancreatitis September 2013

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