Diagnosis, severity stratification and management of adult acute pancreatitis–current evidence and controversies

Abstract

Acute pancreatitis (AP) is a disease spectrum ranging from mild to severe with an unpredictable natural course. Majority of cases (80%) are mild and self-limiting. However, severe AP (SAP) has a mortality risk of up to 30%. Establishing aetiology and risk stratification are essential pillars of clinical care. Idiopathic AP is a diagnosis of exclusion which should only be used after extended investigations fail to identify a cause. Tenets of management of mild AP include pain control and management of aetiology to prevent recurrence. In SAP, patients should be resuscitated with goal-directed fluid therapy using crystalloids and admitted to critical care unit. Routine prophylactic antibiotics have limited clinical benefit and should not be given in SAP. Patients able to tolerate oral intake should be given early enteral nutrition rather than nil by mouth or parenteral nutrition. If unable to tolerate per-orally, nasogastric feeding may be attempted and routine post-pyloric feeding has limited evidence of clinical benefit. Endoscopic retrograde cholangiopancreatogram should be selectively performed in patients with biliary obstruction or suspicion of acute cholangitis. Delayed step-up strategy including percutaneous retroperitoneal drainage, endoscopic debridement, or minimal-access necrosectomy are sufficient in most SAP patients. Patients should be monitored for diabetes mellitus and pseudocyst.

Keywords: Atlanta classification, Drainage, Infections, Necrosectomy, Pancreatitis, Risk stratification

Core Tip: Acute pancreatitis (AP) is a dynamic and evolving pathology with unpredictable natural course and no specific therapy. Most patients have mild and self-limiting AP where supportive therapy is sufficient. Still, an estimated 20% of patients may have severe AP that consumes healthcare resources and contributes to mortality risk. Risk stratification tools guide clinicians in resource allocation, patient counselling, and clinical audit. A multidisciplinary approach including evidence-based care is integral for good clinical outcomes. With regards to necrotizing pancreatitis, too much, too early and too little, too late should be avoided, and step-up philosophy of intervention should be adopted.