Mistakes in the management of acute pancreatitis and how to avoid them

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Mistakes in the management of acute pancreatitis and how to avoid them

Peter Simon, Markus M. Lerch, Julia Mayerle, Georg Beyer, Elisabeth Orgler-Gasche

Summary

AI Generated

Acute pancreatitis is most commonly caused by alcohol and gallstones, with 80–85% of cases being mild while the remainder require intensive multidisciplinary care for potentially life-threatening complications.

Excessive alcohol consumption and gallstone disease are by far the most common risk factors for acute pancreatitis, while certain drugs, genetic mutations, and possibly smoking are also associated with its development
80–85% of patients have mild disease and recover with fluid therapy and analgesia, while the remainder develop moderately severe to severe disease with pancreatic necrosis, severe sepsis, or abdominal compartment syndrome
Patients with severe disease are at immediate danger of multiorgan failure and death and require multidisciplinary intensive care, organ support, and often pancreatic interventions by experienced investigators
Treatment in specialized high-volume centres is recommended because outcomes are difficult to predict and complications develop during the disease course

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7

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Zorniak M, Beyer G and Mayerle J. Risk Stratification and Early Conservative Treatment of Acute Pancreatitis. Visceral Medicine 2019; 35: 82-89. [Link]

10.

Gardner TB, Vege SS, Chari ST, et al. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2009; 9: 770-776. [Link]

11.

Mao EQ, Fei J, Peng YB, et al. Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chinese medical journal 2010; 123: 1639-1644. [Link]

12.

Mao EQ, Tang YQ, Fei J, et al. Fluid therapy for severe acute pancreatitis in acute response stage. Chinese medical journal 2009; 122: 169-173. [Link]

13.

Holodinsky JK, Roberts DJ, Ball CG, et al. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis. Crit Care 2013; 17: R249. [Link]

14.

Kirkpatrick AW, Sugrue M, McKee JL, et al. Update from the Abdominal Compartment Society (WSACS) on intra-abdominal hypertension and abdominal compartment syndrome: past, present, and future beyond Banff 2017. Anaesthesiol Intensive Ther 2017; 49: 83-87. [Link]

15.

Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9: 710-717 e711. [Link]

16.

Investigators P, Rowan KM, Angus DC, et al. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med 2017; 376: 2223-2234. [Link]

17.

de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. New England Journal of Medicine 2022; 387: 989-1000. [Link]

18.

Sun Y, Lu ZH, Zhang XS, et al. The effects of fluid resuscitation according to PiCCO on the early stage of severe acute pancreatitis. Pancreatology 2015; 15: 497-502. [Link]

19.

Huber W, Umgelter A, Reindl W, et al. Volume assessment in patients with necrotizing pancreatitis: a comparison of intrathoracic blood volume index, central venous pressure, and hematocrit, and their correlation to cardiac index and extravascular lung water index. Crit Care Med 2008; 36: 2348-2354. [Link]

20.

Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2018; 25: 17-30. [Link]

21.

Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci 2018; 25: 31-40. [Link]

22.

Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491. [Link]

23.

van Santvoort HC, Besselink MG, de Vries AC, et al. Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg 2009; 250: 68-75. [Link]

24.

Schepers NJ, Hallensleben NDL, Besselink MG, et al. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 2020; 396: 167-176. [Link]

25.

Hallensleben ND, Stassen PMC, Schepers NJ, et al. Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study. Gut 2023;72:1534-1542. [Link]

26.

da Costa DW, Bouwense SA, Schepers NJ, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. The Lancet 2015; 386: 1261-1268. [Link]

27.

da Costa DW, Schepers NJ, Romkens TE, et al. Endoscopic sphincterotomy and cholecystectomy in acute biliary pancreatitis. Surgeon 2016; 14: 99-108. [Link]

28.

Di Martino M, Ielpo B, Pata F, et al. Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis. JAMA Surg 2023; 158: e233660. [Link]

29.

van Brunschot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58. [Link]

30.

Bang JY, Arnoletti JP, Holt BA, et al. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156: 1027-1040.e1023. [Link]

31.

Boxhoorn L, van Dijk SM, van Grinsven J, et al. Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. N Engl J Med 2021; 385: 1372-1381. [Link]

32.

Bang JY, Lakhtakia S, Thakkar S, et al. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol 2024; 9: 22-33. [Link]

33.

Siriwardena AK, Jegatheeswaran S, Mason JM, et al. A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. The Lancet Gastroenterol & Hepatol 2022; 7: 913–921 [Link]

34.

Bakker OJ, van Brunschot S, Farre A, et al. Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials. Pancreatology 2014; 14: 340-346. [Link]

35.

Bakker OJ, van Brunschot S, van Santvoort HC, et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014; 371: 1983-1993. [Link]

Abstract

By far the most common risk factors for the development of acute pancreatitis are excessive alcohol consumption and gallstone disease. Several mutations have been identified that, in combination with nongenetic factors or alone, can lead to pancreatitis. Certain drugs are known to be associated with the development of pancreatitis and smoking might also increase the probability of it developing. 80–85% of patients diagnosed with the disease will have mild disease and make an uneventful recovery with little more than adequate fluid therapy and analgesia needed to support them. The remaining patients, however, will suffer from moderately severe to severe acute pancreatitis, with the development of pancreatic necrosis, severe sepsis or abdominal compartment syndrome. These patients are at immediate danger of multiorgan failure and death and require multidisciplinary intensive care, organ support and often pancreatic interventions conducted by experienced investigators. Since it is difficult to predict outcomes and complications develop during the disease course, treatment in specialized centres that have a high case load is recommended.4

Topics

Pancreas

Citation

Beyer G, et al. Mistakes in the management of acute pancreatitis and how to avoid them. UEG Education 2016: 16: 27–30.

Published

2024

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ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

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Summary

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Summary is not available for this content yet.

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Guideline

Introduction

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Publisher

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Guideline

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Topics

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Citation

Journal of Crohn's and Colitis, Volume 20, Issue 7, July 2026

Published

2026