Acute and chronic pancreatitis - clinical practice guideline

Key points

• Acute pancreatitis is diagnosed when at least two of three criteria are met: typical abdominal pain, serum lipase at least three times the upper limit of normal, and characteristic imaging findings; only lipase (not amylase) is recommended.
• Gallstones and alcohol each cause 30% to 50% of cases; hypertriglyceridemia accounts for about 10%, and smoking is a major risk factor.
• Fluids should be given as Ringer's lactate, initially 200-250 mL per hour; severe pain should be treated with opioids.
• Patients with mild pancreatitis should be offered oral food within the first day; antibiotic prophylaxis cannot be generally recommended.
• In mild biliary pancreatitis, cholecystectomy should be performed during the initial hospital stay.

Overview

This article presents the German S3 clinical practice guideline on pancreatitis. In Germany the incidence of acute pancreatitis is 13 to 43 per 100,000 population and rising, and in 2017, 24 per 100,000 were hospitalized for chronic pancreatitis. The guideline covers diagnosis, severity assessment, acute treatment, complications and follow-up of acute and chronic pancreatitis.

Severity and imaging

Severity is classified retrospectively with the revised Atlanta classification; persistent organ failure (over 48 hours) is the best predictor of mortality. SIRS on admission has a sensitivity of 85% to 100% for a severe course, and its absence a negative predictive value of 98% to 100%. The degree of lipase elevation does not correlate with severity. If the diagnosis is unclear, transabdominal ultrasound comes first; CT to assess necrosis should not be performed within the first three days.

Treatment of acute pancreatitis

In one study, fluid of at least 6000 mL in the first 24 hours was associated with lower mortality, while less than 150 mL per hour on day 1 was disadvantageous and more than 250 mL per hour showed no benefit. In a meta-analysis, early feeding reduced the composite of death, infected necrosis and organ failure from 45% to 19%; nasojejunal and nasogastric tube feeding are considered equivalent. Patients with unfavorable prognostic markers should be transferred to intensive care. ERCP with sphincterotomy is indicated for concomitant cholangitis, confirmed bile duct stones or biliary obstruction. Infected necrosis occurs in about 20% to 40% of severe cases; mortality was 35.2% with organ failure versus 1.4% without, and intervention follows an endoscopic step-up approach when clinically necessary.

Follow-up and chronic pancreatitis

Patients over 40 with a first episode of unexplained acute pancreatitis should have contrast-enhanced cross-sectional imaging or endoscopic ultrasound within three months to rule out pancreatic cancer. Alcohol is the most common confirmed cause of chronic pancreatitis. Exocrine insufficiency should be tested with fecal elastase 1 or a 13C breath test; endoscopic ultrasound, CT and MRI are the most accurate imaging methods. Pregabalin may be tried as an addition to pain management, and pseudocysts should be drained endoscopically first. In hereditary pancreatitis, pancreatic cancer risk is increased 9- to 70-fold, so annual surveillance is advised from age 40 or 20 years after symptom onset.

Frequently asked questions

How is acute pancreatitis diagnosed?

When at least two of three criteria are present: typical upper abdominal pain, lipase at least three times the upper limit of normal, and characteristic imaging findings.

Which fluid is recommended?

Ringer's lactate, initially at 200-250 mL per hour.

Should antibiotics be given to prevent infection?

Not routinely; antibiotic prophylaxis cannot be generally recommended, even in predicted severe pancreatitis.

Source

Beyer G, Hoffmeister A, Lorenz P, Lynen P, Lerch MM, Mayerle J. Clinical practice guideline: Acute and chronic pancreatitis. Dtsch Arztebl Int. 2022;119:495-501. DOI: 10.3238/arztebl.m2022.0223. Summary of the German S3 guideline of the DGVS (AWMF register number 021-003). This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.