Management Algorithm for Severe Acute Pancreatitis.

A commonly used classification system (the Atlanta classification) divides Acute Pancreatitis into two broad categories [5]:

• Mild (edematous and interstitial) acute pancreatitis
• Severe (usually synonymous with necrotizing) acute pancreatitis

The criteria for severe AP included any of the following:

• A Ranson's score of 3 or more (table 1) (calculator 1)
• An APACHE II score of 8 or more within the first 48 hours (calculator 2)
• Organ failure (respiratory, circulatory, renal, and/or gastrointestinal bleeding)
• Local complications (pancreatic necrosis, abscess, or pseudocyst).

SUMMARY AND RECOMMENDATIONS (from UpToDate)

• Acute pancreatitis can be divided into two broad categories: Edematous or mild acute pancreatitis and necrotizing or severe acute pancreatitis. (See 'Introduction' above.) Treatment varies depending on the severity of the condition. (See "Predicting the severity of acute pancreatitis".)
• Mild pancreatitis is treated for several days with supportive care including pain control, intravenous fluids, correction of electrolyte and metabolic abnormalities, and nothing by mouth. The majority of patients require no further therapy, and recover and eat within three to seven days. (See 'Supportive care' above.)
• In severe pancreatitis, intensive care unit monitoring and support of pulmonary, renal, circulatory, and hepatobiliary function may minimize systemic sequelae. (See 'Supportive care' above.)
• Abdominal pain is often the dominant symptom. Adequate pain control requires the use of intravenous opiates, such as meperidine and fentanyl, usually in the form of a patient controlled analgesia pump. (See 'Pain management' above.)
• In patients with mild pancreatitis, recovery generally occurs quickly, making it generally unnecessary to initiate supplemental nutrition. Soft diet can be started after resolution of pain. (See 'Initiation of oral feeding' above.)
• In patients with severe pancreatitis, we recommend attempting to provide early enteral nutrition in the first 72 hours through a nasojejunal tube placed endoscopically or radiologically (Grade 1B). If the target rate is not achieved within a few days and if severe acute pancreatitis is not resolved, supplemental parenteral nutrition should be provided. (See 'Enteral feeding' above.)
• The occurrence of pancreatic infection is a leading cause of morbidity and mortality in acute necrotizing pancreatitis. We suggest prophylactic imipenem or meropenem in patients with necrosis that involves more than 30 percent of the pancreas (Grade 2B). However, not all guidelines recommend the routine use of antibiotics and it is reasonable to withhold antibiotics unless there is clinical or microbiologic evidence of infection. (See 'Infection' above.)
• We suggest using an algorithm (algorithm 1) based upon clinical and CT findings to direct percutaneous aspiration, antibiotic therapy, and minimally invasive or open surgical debridement as needed (Grade 2B). (See 'Infection' above.)
• In patients with gallstone pancreatitis, we recommend early ERCP and sphincterotomy for those who have a high suspicion of cholestasis and those with cholangitis (Grade 1B). Cholecystectomy should be performed after recovery in all patients with gallstone pancreatitis. (See 'Gallstone pancreatitis' above.)

ACKNOWLEDGMENT — The author and UpToDate would like to thank Dr. Suresh T. Chari, who contributed to earlier versions of this topic review

Management Algorithm for Severe Acute Pancreatitis.

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