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American College of Gastroenterology guidelines for the management of acute pancreatitis

This week's issue of the American Journal of Gastroenterology reports on the American College of Gastroenterology guidelines for the management of acute pancreatitis.

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Dr Santhi Swaroop Vege and colleagues from Minnesota, USA present recommendations for the management of patients with acute pancreatitis.

During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease.

As the diagnosis of acute pancreatitis is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically.

Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed.

The team report that patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible.

Prophylactic antibiotics in severe acute pancreatitis is not recommended
American Journal of Gastroenterology

Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it.

The research team noted that early aggressive intravenous hydration is most beneficial within the first 1224 hours, and may have little benefit beyond.

Patients with acute pancreatitis, and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours of admission.

The team reported that pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients.

Routine use of prophylactic antibiotics in patients with severe acute pancreatitis, and/or sterile necrosis is not recommended.

In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality.

In mild acute pancreatitis, oral feedings can be started immediately if there is no nausea and vomiting.

The team observed that in severe acute pancreatitis, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided.

Dr Vege's team concludes, "Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension."

"In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis."

Am J Gastroenterol 2013; 108:14001415
26 September 2013

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