Updates in the Management of Acute Pancreatitis

  • Giampaolo Perri
  • Giovanni MarchegianiEmail author
  • Claudio Bassi


This chapter reviews the current state of the art of clinical management in acute pancreatitis, a disease that continues to be a leading gastrointestinal cause of hospitalization and severe morbidity and mortality.

For most of the cases, a self-limiting illness, acute pancreatitis is for a minority of patients a life-threatening condition, associated with elevated morbidity and mortality, mainly driven by organ failure and infectious complications, despite improvements in access to centers of expertise, imaging, and interventional techniques and the availability of clinical practice guidelines.

In the modern era, early triage, improvements in intensive care management, nutritional support, and timely and appropriate intervention for local complications with less invasive approaches represent the cornerstones of the treatment. The current guidelines, recent literature, and up-to-date interventional techniques are here reviewed and discussed.


  1. 1.
    Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas. 2006;33:323–30.Google Scholar
  2. 2.
    Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143:1179.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Singh VK, Bollen TL, Wu BU, et al. An assessment of the severity of interstitial pancreatitis. Clin Gastroenterol Hepatol. 2011;9:1098.PubMedPubMedCentralGoogle Scholar
  4. 4.
    van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141:1254.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Gloor B, Müller CA, Worni M, et al. Late mortality in patients with severe acute pancreatitis. Br J Surg. 2001;88:975.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Mutinga M, Rosenbluth A, Tenner SM, et al. Does mortality occur early or late in acute pancreatitis? Int J Pancreatol. 2000;28:91.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Banks PA, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–11.PubMedGoogle Scholar
  8. 8.
    Marshall JC, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Gomatos IP, et al. Prognostic markers in acute pancreatitis. Expert Rev Mol Diagn. 2014;14:333–46.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13:e1.Google Scholar
  11. 11.
    Buter A, et al. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg. 2002;89:298–302.Google Scholar
  12. 12.
    American College of Chest Physicians/Society of Critical Care Medicine consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864–74.Google Scholar
  13. 13.
    Talukdar R, et al. Early management of severe acute pancreatitis. Curr Gastroenterol Rep. 2011;13:123.Google Scholar
  14. 14.
    Trikudanathan G, et al. Current controversies in fluid resuscitation in acute pancreatitis: a systematic review. Pancreas. 2012;41:827.Google Scholar
  15. 15.
    Gardner TB, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in hospital mortality. Pancreatology. 2009;9:770.Google Scholar
  16. 16.
    Wu BU, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9:710–7.Google Scholar
  17. 17.
    Mao EQ, et al. Fluid therapy for severe acute pancreatitis in acute response stage. Chin Med J. 2009;122:169–73.Google Scholar
  18. 18.
    Mao EQ, et al. Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J. 2010;123:1639–44.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Basurto Ona X, et al. Opioids for acute pancreatitis pain. Cochrane Database Syst Rev. 2013;(7):CD009179.Google Scholar
  20. 20.
    Eatock FC, et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100:432–9.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Kumar A, et al. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol. 2006;40:431–4.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Al-Omran M, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2010;(1):CD002837.Google Scholar
  23. 23.
    Petrov MS, et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg. 2008;143:1111–7.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Villatoro E, et al. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev. 2010;(5):CD002941.Google Scholar
  25. 25.
    Wittau M, et al. Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol. 2011;46:261–70.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Kirkpatrick AW, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013;39:1190–206.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Lenhart DK, Balthazar EJ. MDCT of acute mild (nonnecrotizing) pancreatitis: abdominal complications and fate of fluid collections. AJR Am J Roentgenol. 2008;190:643.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Mier J, et al. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173:71–5.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006;101:2379.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Beger HG, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis. A prospective clinical study. Gastroenterology. 1986;91:433.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Bradley EL 3rd, Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. Am J Surg. 1991;161:19.Google Scholar
  32. 32.
    Buchler M, et al. Acute pancreatitis: when and how to operate. Dig Dis. 1992;10:354–62.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Rodriguez JR, Razo AO, Targarona J, Thayer SP, Rattner DW, Warshaw AL, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg. 2008;247:294–9.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Beck WC, Bhutani MS, Raju GS, Nealon WH. Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis. J Am Coll Surg. 2012;214:682–8.PubMedPubMedCentralGoogle Scholar
  35. 35.
    van Santvoort HC, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–502.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Bakker OJ, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307:1053–61.PubMedPubMedCentralGoogle Scholar
  37. 37.
    van Brunschot S, et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol. 2013;13:161.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Sorrentino L, Chiara O, Mutignani M, et al. Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review. World J Emerg Surg. 2017;12:16.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg. 2010;251:787–93.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Carter CR, et al. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg. 2000;232:175–80.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Horvath KD, et al. A technique for laparoscopic-assisted percutaneous drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc. 2001;15:1221–5.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Gibson SC, et al. ‘Step-port’ laparoscopic cystogastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis. HPB (Oxford). 2014;16:170–6.Google Scholar
  43. 43.
    Bradley EL 3rd. Management of infected pancreatic necrosis by open drainage. Ann Surg. 1987;206:542–50.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Heinrich S, et al. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006;243:154–68.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Radenkovic DV, et al. Planned staged reoperative necrosectomy using an abdominal zipper in the treatment of necrotizing pancreatitis. Surg Today. 2005;35:833–40.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Pezzilli R, et al. A prospective multicentre survey on the treatment of acute pancreatitis in Italy. Dig Liver Dis. 2007;39:838–46.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Fernandez-del Castillo C, et al. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg. 1998;228:676–84.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Wig JD, et al. Closed lesser sac lavage in the management of pancreatic necrosis. J Gastroenterol Hepatol. 2004;19:1010–5.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev. 2012;5:CD009779.Google Scholar
  50. 50.
    Nealon WH, Bawduniak J, Walser EM. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann Surg. 2004;239:741–9.PubMedPubMedCentralGoogle Scholar
  51. 51.
    da Costa DW, Bouwense SA, Schepers NJ. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015;386(10000):1261–8.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Giampaolo Perri
    • 1
  • Giovanni Marchegiani
    • 1
    Email author
  • Claudio Bassi
    • 1
  1. 1.Department of SurgeryPancreas Institute, Verona University HospitalVeronaItaly

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