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Article: Practice guidelines in acute pancreatitis

TitlePractice guidelines in acute pancreatitis
Authors
Issue Date2006
PublisherNature Publishing Group. The Journal's web site is located at http://www.nature.com/ajg/index.html
Citation
American Journal Of Gastroenterology, 2006, v. 101 n. 10, p. 2379-2400 How to Cite?
AbstractThe diagnosis of acute pancreatitis requires two of the following three features: 1) characteristic abdominal pain, 2) serum amylase and/or lipase ≥3 times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on CT scan. Risk factors of severity of acute pancreatitis at admission include older age, obesity, and organ failure. Tests at admission that are also helpful in distinguishing mild from severe acute pancreatitis include APACHE-II score ≥8 and serum hematocrit (a value <44 strongly suggests mild acute pancreatitis). An APACHE-II score that continues to increase for the first 48 h strongly suggests the development of severe acute pancreatitis. A CRP >150 mg/L within the first 72 h strongly correlates with the presence of pancreatic necrosis. The two most important markers of severity in acute pancreatitis are organ failure (particularly multisystem organ failure) and pancreatic necrosis. Contrast-enhanced CT scan is the best available test to distinguish interstitial from necrotizing pancreatitis, particularly after 2-3 days of illness. Mortality of sustained multisystem organ failure in association with necrotizing pancreatitis is generally >36%. Supportive care includes vigorous fluid resuscitation that can be monitored in a variety of ways including a progressive decrease in serum hematocrit at 12 and 24 h. Supplemental oxygen should be administered during the first 24-48 h, bedside oxygen saturation monitored at frequent intervals, and blood gases obtained when clinically indicated, particularly when oxygen saturation is ≤95%. Transfer to an intensive care unit is recommended if there is sustained organ failure or if there are other indications that the pancreatitis is severe including oliguria, persistent tachycardia, and labored respiration. Patients who are unlikely to resume oral nutrition within 5 days because of sustained organ failure or other indications require nutritional support. Nutiritional support can be provided by TPN or by enteral feeding. There appear to be some advantages to enteral feeding. Patients with acute pancreatitis caused by gallstones, who are strongly suspected of harboring common bile duct stones on the basis of organ failure or other signs of severe systemic toxicity (marked leukocytosis and/or fever), require evaluation for the presence of choledocholithiasis, preferably within the first 24 h of admission. ERCP with endosocopic biliary sphincterotomy and stone removal are indicated for patients with cholangitis, severe acute pancreatitis, or high clinical suspicion or definitive demonstration of persistent bile duct stones by other imaging techniques. Expectant management with interval cholecystectomy including intraoperative cholangiogram is appropriate for most patients with mild to moderate pancreatitis and an improving clinical course. Routine precholecystectomy ERCP is not recommended in patients with biliary pancreatitis. In ambiguous cases, where available, evaluation for bile duct stones can beperformed by endoscopic ultrasound or MRCP. The use of prophylactic antibiotics in necrotizing pancreatitis is not recommended in view of a recent prospective randomized double-blind trial that showed no benefit and in view of the concern that the prolonged use of potent antibiotic agents may lead to the emergence of resistant Gram-positive organisms and fungal infections in the necrotic pancreas. It is reasonable to administer appropriate antibiotics in necrotizing pancreatitis associated with fever, leukocytosis, and/or organ failure while appropriate cultures (including culture of CT-guided percutaneous aspiration of the pancreas) are obtained. Antibiotics should then be discontinued if no source of infection is found. CT-guided percutaneous aspiration with Gram's stain and culture is recommended when infected pancreatic necrosis is suspected. Treatment of choice of infected necrosis is surgical debridement. The timing of surgery is left to the discretion of the pancreatic surgeon. Patients who are medically unfit for open surgical debridement can be treated with less invasive surgical techniques, radiologic techniques, and, at times, endoscopic techniques in medical centers with these capabilities. Treatment of sterile pancreatic necrosis is generally medical during the first several weeks even in the presence of multisystem organ failure. Eventually, after the acute inflammatory process has subsided and coalesced into an encapsulated structure that is frequently called organized necrosis, debridement may be required for intractable abdominal pain, intractable nausea or vomiting caused by extrinsic compression of stomach or duodenum, or systemic toxicity (fever and/or intractable malaise). Debridement can be performed by surgical, endoscopic, or radiologic techniques. © 2006 by Am. Coll. of Gastroenterology.
Persistent Identifierhttp://hdl.handle.net/10722/163028
ISSN
2015 Impact Factor: 10.383
2015 SCImago Journal Rankings: 3.946
ISI Accession Number ID
References

 

DC FieldValueLanguage
dc.contributor.authorBanks, PAen_US
dc.contributor.authorFreeman, MLen_US
dc.contributor.authorFass, Ren_US
dc.contributor.authorBaroni, DSen_US
dc.contributor.authorMutlu, EAen_US
dc.contributor.authorBernstein, DEen_US
dc.contributor.authorParkman, HPen_US
dc.contributor.authorBharucha, AEen_US
dc.contributor.authorPrather, Cen_US
dc.contributor.authorBrugge, WRen_US
dc.contributor.authorPratt, DSen_US
dc.contributor.authorChang, Len_US
dc.contributor.authorRoach, ACen_US
dc.contributor.authorChey, Wen_US
dc.contributor.authorSampliner, REen_US
dc.contributor.authorCohen, MEen_US
dc.contributor.authorSridhar, Sen_US
dc.contributor.authorCunningham, JTen_US
dc.contributor.authorVakil, Nen_US
dc.contributor.authorEdmundowicz, SAen_US
dc.contributor.authorValdovinos, MAen_US
dc.contributor.authorInadomi, JMen_US
dc.contributor.authorWong, BCYen_US
dc.contributor.authorKoch, TRen_US
dc.contributor.authorZfass, AMen_US
dc.date.accessioned2012-09-05T05:26:45Z-
dc.date.available2012-09-05T05:26:45Z-
dc.date.issued2006en_US
dc.identifier.citationAmerican Journal Of Gastroenterology, 2006, v. 101 n. 10, p. 2379-2400en_US
dc.identifier.issn0002-9270en_US
dc.identifier.urihttp://hdl.handle.net/10722/163028-
dc.description.abstractThe diagnosis of acute pancreatitis requires two of the following three features: 1) characteristic abdominal pain, 2) serum amylase and/or lipase ≥3 times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on CT scan. Risk factors of severity of acute pancreatitis at admission include older age, obesity, and organ failure. Tests at admission that are also helpful in distinguishing mild from severe acute pancreatitis include APACHE-II score ≥8 and serum hematocrit (a value <44 strongly suggests mild acute pancreatitis). An APACHE-II score that continues to increase for the first 48 h strongly suggests the development of severe acute pancreatitis. A CRP >150 mg/L within the first 72 h strongly correlates with the presence of pancreatic necrosis. The two most important markers of severity in acute pancreatitis are organ failure (particularly multisystem organ failure) and pancreatic necrosis. Contrast-enhanced CT scan is the best available test to distinguish interstitial from necrotizing pancreatitis, particularly after 2-3 days of illness. Mortality of sustained multisystem organ failure in association with necrotizing pancreatitis is generally >36%. Supportive care includes vigorous fluid resuscitation that can be monitored in a variety of ways including a progressive decrease in serum hematocrit at 12 and 24 h. Supplemental oxygen should be administered during the first 24-48 h, bedside oxygen saturation monitored at frequent intervals, and blood gases obtained when clinically indicated, particularly when oxygen saturation is ≤95%. Transfer to an intensive care unit is recommended if there is sustained organ failure or if there are other indications that the pancreatitis is severe including oliguria, persistent tachycardia, and labored respiration. Patients who are unlikely to resume oral nutrition within 5 days because of sustained organ failure or other indications require nutritional support. Nutiritional support can be provided by TPN or by enteral feeding. There appear to be some advantages to enteral feeding. Patients with acute pancreatitis caused by gallstones, who are strongly suspected of harboring common bile duct stones on the basis of organ failure or other signs of severe systemic toxicity (marked leukocytosis and/or fever), require evaluation for the presence of choledocholithiasis, preferably within the first 24 h of admission. ERCP with endosocopic biliary sphincterotomy and stone removal are indicated for patients with cholangitis, severe acute pancreatitis, or high clinical suspicion or definitive demonstration of persistent bile duct stones by other imaging techniques. Expectant management with interval cholecystectomy including intraoperative cholangiogram is appropriate for most patients with mild to moderate pancreatitis and an improving clinical course. Routine precholecystectomy ERCP is not recommended in patients with biliary pancreatitis. In ambiguous cases, where available, evaluation for bile duct stones can beperformed by endoscopic ultrasound or MRCP. The use of prophylactic antibiotics in necrotizing pancreatitis is not recommended in view of a recent prospective randomized double-blind trial that showed no benefit and in view of the concern that the prolonged use of potent antibiotic agents may lead to the emergence of resistant Gram-positive organisms and fungal infections in the necrotic pancreas. It is reasonable to administer appropriate antibiotics in necrotizing pancreatitis associated with fever, leukocytosis, and/or organ failure while appropriate cultures (including culture of CT-guided percutaneous aspiration of the pancreas) are obtained. Antibiotics should then be discontinued if no source of infection is found. CT-guided percutaneous aspiration with Gram's stain and culture is recommended when infected pancreatic necrosis is suspected. Treatment of choice of infected necrosis is surgical debridement. The timing of surgery is left to the discretion of the pancreatic surgeon. Patients who are medically unfit for open surgical debridement can be treated with less invasive surgical techniques, radiologic techniques, and, at times, endoscopic techniques in medical centers with these capabilities. Treatment of sterile pancreatic necrosis is generally medical during the first several weeks even in the presence of multisystem organ failure. Eventually, after the acute inflammatory process has subsided and coalesced into an encapsulated structure that is frequently called organized necrosis, debridement may be required for intractable abdominal pain, intractable nausea or vomiting caused by extrinsic compression of stomach or duodenum, or systemic toxicity (fever and/or intractable malaise). Debridement can be performed by surgical, endoscopic, or radiologic techniques. © 2006 by Am. Coll. of Gastroenterology.en_US
dc.languageengen_US
dc.publisherNature Publishing Group. The Journal's web site is located at http://www.nature.com/ajg/index.htmlen_US
dc.relation.ispartofAmerican Journal of Gastroenterologyen_US
dc.subject.meshHumansen_US
dc.subject.meshPancreatitis - Complications - Diagnosis - Therapyen_US
dc.subject.meshSeverity Of Illness Indexen_US
dc.titlePractice guidelines in acute pancreatitisen_US
dc.typeArticleen_US
dc.identifier.emailWong, BCY:bcywong@hku.hken_US
dc.identifier.authorityWong, BCY=rp00429en_US
dc.description.naturelink_to_subscribed_fulltexten_US
dc.identifier.doi10.1111/j.1572-0241.2006.00856.xen_US
dc.identifier.pmid17032204en_US
dc.identifier.scopuseid_2-s2.0-33749170457en_US
dc.relation.referenceshttp://www.scopus.com/mlt/select.url?eid=2-s2.0-33749170457&selection=ref&src=s&origin=recordpageen_US
dc.identifier.volume101en_US
dc.identifier.issue10en_US
dc.identifier.spage2379en_US
dc.identifier.epage2400en_US
dc.identifier.isiWOS:000240915100031-
dc.publisher.placeUnited Statesen_US
dc.identifier.scopusauthoridBanks, PA=25649074300en_US
dc.identifier.scopusauthoridFreeman, ML=7402429820en_US
dc.identifier.scopusauthoridFass, R=7103304557en_US
dc.identifier.scopusauthoridBaroni, DS=24178890500en_US
dc.identifier.scopusauthoridMutlu, EA=6701371965en_US
dc.identifier.scopusauthoridBernstein, DE=7401750061en_US
dc.identifier.scopusauthoridParkman, HP=7007147227en_US
dc.identifier.scopusauthoridBharucha, AE=7004518505en_US
dc.identifier.scopusauthoridPrather, C=7003643388en_US
dc.identifier.scopusauthoridBrugge, WR=7006095362en_US
dc.identifier.scopusauthoridPratt, DS=7201541586en_US
dc.identifier.scopusauthoridChang, L=7404274800en_US
dc.identifier.scopusauthoridRoach, AC=24178996500en_US
dc.identifier.scopusauthoridChey, W=26535765700en_US
dc.identifier.scopusauthoridSampliner, RE=7102183022en_US
dc.identifier.scopusauthoridCohen, ME=8093607200en_US
dc.identifier.scopusauthoridSridhar, S=16022992300en_US
dc.identifier.scopusauthoridCunningham, JT=35464682800en_US
dc.identifier.scopusauthoridVakil, N=7102106058en_US
dc.identifier.scopusauthoridEdmundowicz, SA=7003375477en_US
dc.identifier.scopusauthoridValdovinos, MA=6701717743en_US
dc.identifier.scopusauthoridInadomi, JM=7004004459en_US
dc.identifier.scopusauthoridWong, BCY=7402023340en_US
dc.identifier.scopusauthoridKoch, TR=7203010260en_US
dc.identifier.scopusauthoridZfass, AM=7003672793en_US
dc.identifier.citeulike880292-

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