Acute pancreatitis is a leading gastrointestinal cause of inpatient care. More than 275,000 patients are hospitalized per year in the U.S. and evidence suggests that its incidence is on the rise.The American Gastroenterological Association (AGA) has released its new clinical guideline on the initial management of acute pancreatitis (AP) that provides up-to-date recommendations for early treatment decisions in acute pancreatitis. The guideline has been published online in the journal Gastroenterology.
The guidelines will promote consistent practices and quality care regarding clinical decisions made within the first 48 to 72 hours of hospital admission for acute pancreatitis.These recommendations on goal-directed fluid resuscitation, early oral feeding, enteral vs. parenteral nutrition, routine prophylactic antibiotic use and routine endoscopic retrograde cholangiopancreatography (ERCP) can alter the course of disease and duration of hospitalization.
“Emerging evidence challenges many of the long-held management paradigms in acute pancreatitis regarding the benefit of antibiotics, the timing and mode of nutritional support, and the utility and timing of endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy,” noted the research group.
Strong recommendations are expected to apply to most patients, whereas conditional recommendations involve more individualized decision-making, including the potential use of formal patient decision aids to facilitate choices consistent with their values and preferences.
Strong recommendations :
- Oral feeding should be given within 24 hours as tolerated rather than following the “nothing by mouth” or nil per os (NPO) practice;
- Enteral rather than parenteral nutrition should be used in patients who are unable to feed orally;
- Cholecystectomy should be performed at initial admission in patients with acute biliary pancreatitis, rather than after they are discharged; and
- A brief alcohol intervention should be performed during admission in patients with acute alcohol-induced pancreatitis.
- Compared with conservative management, urgent ERCP (Endoscopic retrograde cholangiopancreatography) had no impact on outcomes, including mortality
Conditional recommendations :
- Goal-directed therapy for fluid management should be used; while the committee did not offer a recommendation on whether normal saline or ringer’s lactate should be used, they did suggest against the use of hydroxyethyl starch (HES) fluids;
- Prophylactic antibiotics should not be used in patients with predicted severe or necrotizing acute pancreatitis;
- Routine use of urgent ERCP should not be used in patients with acute biliary pancreatitis without accompanying cholangitis; and
- Either the nasogastric or nasoenteral route should be used for enteral tube feeding if required by patients with predicted severe or necrotizing acute pancreatitis.
The guideline committee concluded that “current evidence supports the benefit of goal-directed fluid resuscitation, early oral feeding, and enteral rather than parenteral nutrition, in all patients with [acute pancreatitis]. Our evidence profiles also support the benefit of same-admission cholecystectomy for patients with biliary pancreatitis, and brief alcohol intervention for patients with alcohol-induced pancreatitis. In contrast, current evidence does not support a benefit for the routine use of prophylactic antibiotics in predicted severe [acute pancreatitis] or routine ERCP in patients with [acute pancreatitis] without accompanying cholangitis.
For further reference log on to : DOI: https://doi.org/10.1053/j.gastro.2018.01.032
Dr. Kamal Kant Kohli
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