1、 There has been an increase in the incidence of acute pancreatitis reported worldwide.Despite improvements in access to care,imaging and interventional techniques,acute pancreatitis continues to be associated with signifcant morbidity and mortality.Despite the availability of clinical practice guide
2、lines for the management of acute pancreatitis,recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations.This underscores the importance of creating understandable and implementable recommendations for the diagnos
3、is and management of acute pancreatitis.The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the gall stoneinduced pancreatitis.MethodologyDiagnosis of acute pancreatitisAssessMent of severitySuppor
4、tive careCONTANTSNutritionProphylactic antibioticsManagement of acute gallstone pancreatitisCONTANTSMethodologyIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.Methodology123 The guideline was developed under the auspices of the Universityof T
5、oronto.They searched Medline for guidelines published between 2019 and 2019 using the Medical Subject Headings“pancreatitis”and“clinical practice guideline.”This search identifed 14 guidelines published between 2019 and 2019.Another electronic search of Medline was performed using the Medical Subjec
6、t Headings“pancreatitis,”“acute necrotizing pancreatitis,”“alcoholic pancreatitis,”and“practice guidelines”to update the systematic review.The results were limited to articles published in English between January 2019 and January 2019.Thereferences of relevant guidelines were reviewed.Up-todate arti
7、cles on acute pancreatitis diagnosis and management were also reviewed for their references.Diagnosis of acute pancreatitisIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.1Diagnosis of acute pancreatitis(2 of the following)Abdominal pain(acut
8、e onset of a persistent,severe,epigastric pain often radiating to the back)Serum lipase activity(or amylase)at least 3 times greater than the upper limit of normal Characteristic findings of acute pancreatitis on computed tomography or magnetic resonance imaging Serum lipase has a slightly higher se
9、nsitivity for detection of acute pancreatitis.One study demonstrated that at day 01 from onset of symptoms,serum lipase had a sensitivity approaching 100%compared with 95%for serum amylase.13 For days 23 at a sensitivity set to 85%,the specifcity of lipase was 82%compared with 68%for amylase.Serum l
10、ipase is therefore especially useful in patients who present late to hospital.2 Right upper quadrant ultrasonography is the primary imaging modality forsuspected acute biliary pancreatitis owing to its low cost,availability and lack of associated radiation exposure.Ultrasonography has a sensitivity
11、and specifcity greater than 95%in the detection of gallstones,although the sensitivity may be slightly lower in the context of ileus with bowel distension,commonly associated with acute pancreatitis.Ultrasonography can also identify gallbladder wall thickening and edema,gallbladder sludge,pericholec
12、ystic fluid and a sonographic Murphy sign,consistent with acute cholecystitis.When these signs are present,the positive predictive value of ultrasonography in the diagnosis of acute cholecystitis is greater than 90%,and additional studies are rarely needed.3Diagnosis of acute pancreatitis4 Magnetic
13、resonance cholangiopancreatography is useful in identifying CBD stones and delineating pancreatic and biliary tract anatomy.A systematic review that included a total of 67 studies found that the overall sensitivity and specificity of MRCP to diagnose biliary obstruction were 95%and 97%,respectively.
14、Sensitivity was slightly lower,at 92%,for detection of biliary stones.5 In severe disease,CT is useful to distinguish between interstitial acute pancreatitis and necrotizing acute pancreatitis and to rule out local complications.However,in acute pancreatitis these distinctions typically occur more t
15、han 34 days from onset of symptoms,which makes CT of limited use on admission.Diagnosis of acute pancreatitisAssessMent of severityIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.1 At 48 hours,serum CRP levels above 14286 nmol/L have a sensit
16、ivity,specifcity,positive predictive value and negative predictive value of 80%,76%,67%,and 86%,respectively,for severe acute pancreatitis.Levels greater than 17 143 nmol/L within the frst 72 hours of disease onset have been correlated with the presence of necrosis with the sensitivity and specifcit
17、y both greater than 80%.Serum CRP generally peaks 3672 hours after disease onset,so the test is not helpful in assessing severity on admission.A variety of reports have correlated a higher APACHE II Score at admission and during the first 72 hours with a higher mortality(4%with an APACHE II Score 8
18、and 11%18%with an APACHE II Score 8).There are some limitations in the ability of the APACHE II Score to stratify patients for disease severity.For example,studies have shown that it has limited ability to distinguish between interstitial and necrotizing acute pancreatitis,which confer different pro
19、gnoses.In a recent report,APACHE II Scores generated within the frst 24 hours had a positive predictive value of only 43%and negative predictive value of 86%for severe acute pancreatitis.2 The organ failurebased criteria for the prediction of severity in acute pancreatitis are taken,in part,from the
20、 modifed Multiple Organ Dysfunction Score presented by Banks and colleagues in their revision of the Atlanta Classifcation.A diagnosis of severe acute pancreatitis should also be made if a patient exhibits signs of persistent organ failure for more than 48 hours despite adequate intravenous fluid re
21、suscitation.3AssessMent of severity Supportive careIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.1 In a RCT(n=40),Wu and colleagues found that after 24 hours of resuscitation there was an 84%reduction in the incidence of SIRS in patients re
22、suscitated with Ringers Lactate(p=0.035)as well as a significant reduction in CRP from 9905 nmol/L to 5143 nmol/L when Ringers Lactate was selected over normal saline(p=0.02).Pain control is an important part of the supportive management of patients with acute pancreatitis.Therefore,in the absence o
23、f any patient-specifc contraindications,a multimodal analgesic regimen is recommended,including narcotics,nonsteroidal anti-inflammatories and acetaminophen.2 However,a systematic review of 26 observational studies showed that critically ill patients cared for by an intensivist or using an intensivi
24、st consultant model in a closead intensive care unit(ICU)had a shorter stay in the ICU and lower mortality than similar patients cared for in units without such staffing patterns.3Supportive careNutritionIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of fo
25、olishness.1 In the past,it was accepted practice that bowel rest would limit the inflammation associated with this process.Recently,however,a series of RCTs have convincingly shown that early oral/enteral feeding in patients with acute pancreatitis is not associated with adverse effects and may be a
26、ssociated with substantial decreases in pain,opioid usage and food intolerance.Eckerwall and colleagues demonstrated that oral feeding on admission for mild acute pancreatitis was associated with a signifcant decrease in length of stay from 6 to 4 days compared with withholding oral food and fluids.
27、The major benefts from early feeding appear to be effective only if feeding is commenced within the frst 48 hours following admission,60 and the current recommendation based on a 2019 meta-analysis of 32 RCTs is to commence oral feeding at the time of admission if tolerated or within the frst 24 hou
28、rs.2 Several meta-analyses have shown similar results,with signifcant reductions in infectious complications,mortality and multiorgan dysfunction when enteral nutrition is commenced within the frst 48 hours following admission.3Nutrition A meta-analysis65 of 4 prospective studies of patients with pr
29、edicted severe acute pancreatitis demonstrated no change in intolerance of feeding or in mortality when given enteral feeds by nasogastric feeding tube versus nasojejunal feeding tube.In a more recent meta analysis of 3 RCTs,Chang found no signifcant differences in mortality,tracheal aspiration,diar
30、rhea,exacerbation of pain and meeting energy balance between patients fed through nasogastric and nasojejunal feeding tubes.Although semi-elemental,immune-enhanced and probiotic enteral feeds showed initial promise in the management of severe acute pancreatitis,meta-analyses still indicate that ther
31、e is insuffcient evidence to recommend the use of any of these nutritional formulations at this time.Given its promise in the context of other critically ill and septic patients,the use of probiotics in the management of acute pancreatitis may yet prove effective as research continues.45NutritionPro
32、phylactic antibioticsIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.1 A 2019 meta-analysis of 7 RCTs involving 404 patients comparing prophylactic antibiotics versus placebo in CT proven necrotizing acute pancreatitis concluded that there wa
33、s no statistically signifcant reduction of mortality with therapy,nor a signifcant reduction in infection rates of pancreatic necrosis In light of the lack of demonstrated beneft of prophylactic antibiotics in the treatment of acute pancreatitis,the adverse effects of this practice must be carefully
34、 considered.In a prospective,randomized controlled trial,Marav-Poma and colleages76 demonstrated a 3-fold increase in the incidence of local and systemic fungal infection with Candida albicans(from 7%to 22%)in patients with prolonged treatment with prophylactic antibiotics,a fnding consistent with t
35、hose of other similar studies.In addition,overuse of antibiotics is associated with the increased risk of antibiotic-associated diarrhea and Clostridium difficile colitis80 and with the selection of resistant organisms,all of which suggest that the adverse effects of prophylactic antibiotic coverage
36、 outweighs any benefit offered by the practice2Prophylactic antibioticsManagement of acute gallstone pancreatitisIt was the best of times,it was the worst of times;it was the age of wisdom,it was the age of foolishness.1 A 2019 Cochrane meta-analysis129 included RCTs comparing early routine ERCP ver
37、sus early conservative management with or without selective use of ERCP in patients with suspected acute gallstone pancreatitis.There were 5 RCTs with a total of 644 patients.Overall,there were no statistically signifcant differences between the 2 treatment strategies in mortality,local or systemic
38、complications as defined by the Atlanta Classifcation.In an RCT from China 130 patients with severe acute gallstone pancreatitis were randomized to early treatment(within 72 h of onset)with ERCP or image-guided percutaneous transhepatic gallbladder drainage(PTGD).Success rates were comparable betwee
39、n the ERCP and PTGD,and 4-month mortality,local complications and systemic complications did not differ signifcantly.The author concluded that PTGD is a safe,effective and minimally invasive option that should be considered for all patientswith severe acute gallstone pancreatitis who are poor candid
40、ates for or who are unable to tolerate ERCP.2Management of acute gallstone pancreatitis4 A systematic review131 of 8 cohort studies(n=948)and1 RCT(n=50)revealed that while the readmission rate for gallstone disease in patients admitted for acute gallstone pancreatitis and discharged without cholecys
41、tectomy was 18%within the frst 58 days after discharge,it was 0%in the cohort that underwent index admission cholecystectomy(p 0.001).These results are supported by several retrospective studies that also cited signifcantly higher recurrence rates of gallstone disease(15%32%)in patients who did not
42、undergo index admission cholecystectomy.The majority of these recurrent attacks occurred before the time of interval cholecystectomy.A systematic review of 8 cohort studies and 1 RCT demonstrated a similar reduction in biliary events from 24%to 10%when patients not undergoing index admission cholecy
43、stectomy underwent ERCP and sphincterotomy before discharge.These data strongly support the consideration of ERCP with sphincterotomy for patients unable to tolerate surgery on the index admission owing to comorbidities or deconditioning.5Management of acute gallstone pancreatitisTHANKSReporter Weirui Ren
