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Guideline recommendation Strength of evidence Guideline recommendation A serum lipase test should be performed in all patients with a suspected diagnosis of acute pancreatitis. Moderate–high Strong Ultrasonography should be performed in all patients at baseline to evaluate the biliary tract to determine if the patient has gallstones and/or a stone in the common bile duct. High Strong Magnetic resonance cholangiopancreatography (MRCP) is recommended only in patients in whom there is elevation of liver enzymes and the common bile duct is either not visualized adequately or is found to be normal on ultrasound. High Strong Computed tomography should be performed selectively when 1) a broad differential diagnosis that includes acute pancreatitis must be narrowed, or 2) in patients with acute pancreatitis and a suspected local complication (e.g., peritonitis, signs of shock, suggestive ultrasound findings). Low–moderate Strong C-reactive protein (CRP) should be assessed at admission and daily for the first 72 h after admission. Low–moderate Weak Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II Scores should be calculated on admission and daily for the first 72 h after admission. Moderate Weak The diagnosis of severe acute pancreatitis should be made if the patient has a serum CRP ≥ 14 286 nmol/L (150 mg/dL) at baseline or in the first 72 h; APACHE Score ≥ 8 at baseline or in the first 72 h; or exhibits signs of persistent organ failure for > 48 h despite adequate intravenous fluid resuscitation. Moderate Strong Supportive care, including resuscitation with isotonic intravenous fluids like Ringer’s Lactate, pain control and mobilization, should be the mainstay of treatment for patients with mild acute pancreatitis. Low Strong Careful consideration of transfer to a monitored unit should be made in patients with Severe acute pancreatitis based on APACHE II Score > 8, CRP > 14 286 nmol/L (150 mg/dL), or organ dysfunction > 48 h despite adequate resuscitation;
Evidence of present or evolving organ dysfunction;
Need for aggressive, ongoing fluid resuscitation.
Low Strong Patients with mild acute pancreatitis should receive a regular diet on admission. If patients initially are unable to tolerate an oral diet owing to abdominal pain, nausea, vomiting, or ileus, they may be allowed to self-advance their diet from withholding oral food and liquid to a regular diet as tolerated. High Strong In patients with severe acute pancreatitis, enteral nutrition should be commenced as soon as possible following admission (within 48 h). High Strong Prophylactic antibiotics are not recommended. High Strong Patients with 1) extensive necrotizing acute pancreatitis, 2) who show no clinical signs of improvement following appropriate initial management, or 3) who experience other complications should be managed in institutions that have on-site or access to therapeutic endoscopy, interventional radiology, surgeons and intensivists with expertise in dealing with severe acute pancreatitis. Moderate Weak Follow-up computed tomography should be based on the clinical status of the patient and not performed routinely at regular intervals. Low Strong Patients with acute peripancreatic fluid collections with no radiological or clinical suspicion of sepsis should be observed, and image-guided fine needle aspiration (FNA) should be avoided owing to the risk of introducing infection into a sterile collection. Moderate Weak When there is radiological or clinical suspicion of infected necrosis in patients with acute necrotic collections (ANCs) or walled-off pancreatic necrosis (WOPN), image-guided FNA with culture should be performed to distinguish infected from sterile necrosis. Moderate Strong Sterile necrosis based on negative FNA and/or stable clinical picture should be managed nonoperatively, and antibiotics are not indicated. For unstable patients in whom sepsis is suspected but no source has been identified, treatment with broad spectrum antibiotics on speculation may be indicated while an appropriate work up (bacterial and fungal cultures, CT scan) is carried out. Moderate Weak In patients with FNA-confirmed infections of ANCs or WOPN, a step-up approach of antibiotics, image-guided drainage, followed by surgical intervention, if necessary, is indicated. Moderate Strong Pancreatic pseudocysts that are asymptomatic should be managed nonoperatively. Intervention is indicated in pseudocysts that are symptomatic, infected, or increasing in size on serial imaging. Moderate Strong Endoscopic retrograde cholangiopancreatography (ERCP) should be performed early (within 24–48 h) in patients with acute gallstone pancreatitis associated with bile duct obstruction or cholangitis. In unstable patients with severe acute gallstone pancreatitis and associated bile duct obstruction or cholangitis, placement of a percutaneous transhepatic gallbladder drainage tube should be considered if ERCP is not safely feasible. Moderate–high Strong Cholecystectomy should be performed during the index admission in patients who have mild acute pancreatitis and delayed until clinical resolution in patients who have severe acute pancreatitis. Moderate Strong If cholecystectomy cannot be performed during the index admission owing to medical comorbidities, patients with acute gallstone pancreatitis should undergo ERCP with sphincterotomy before discharge. Low Weak
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