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Acute pancreatitis (AP) is a disease characterized by acute inflammation of the pancreas and histological destruction of acinar cells.
It is one of the common digestive system emergencies
.
The "Expert Consensus on the Emergency Diagnosis and Treatment of Acute Pancreatitis" aims to help emergency clinical medical staff quickly diagnose and evaluate the condition of AP, and provide standardized treatment in a timely manner, in order to reduce the incidence of later complications and surgical intervention rates, and shorten the length of hospitalization
.
Main recommendations Recommendations 1 The acute pancreatitis bedside severity index (BISAP) score is simple and easy to implement, with high accuracy.
Emergency physicians should complete the BISAP score within 24 hours of admission to early predict the severity of acute pancreatitis
.
Recommendation 2 Patients with persistent organ failure and infectious necrosis are at the highest risk of death
.
Recommendation 3 Use procalcitonin to detect pancreatic infections
.
C-reactive protein level ≥150 mg/L on day 3 can be used as a prognostic factor for severe acute pancreatitis
.
Hematocrit>44% is an independent risk factor for pancreatic necrosis
.
Blood urea nitrogen >20 mg/dL (7.
14 mmol/L) is an independent predictor of death
.
Recommendation 4 The best time for the first enhanced CT evaluation is 72~96h after the onset of disease
.
For critically ill patients, complete abdominal and pelvic enhanced CT and abdominal MRI + magnetic resonance cholangiopancreatography (MRCP) 48 to 72 hours after the onset of symptoms
.
For patients with signs of infection, significant deterioration in clinical status, and gastrointestinal obstruction or signs of infection with peripancreatic effusion for more than 4 weeks, the abdominal and pelvic enhanced CT and abdominal MRI+MRCP should be reviewed
.
MRCP or EUS is used to screen for occult choledocholithiasis
.
MRI helps to determine the status of pancreatic necrosis (sterile and infectious)
.
Recommendation 5 Emergency physicians should use multidisciplinary diagnosis and treatment concepts and models at the beginning of admission for AP patients.
The indication for transfer to the ICU is organ failure for more than 48 hours.
If fatal multi-organ failure occurs, they need to be transferred to the ICU in time
.
Recommendation 6 For patients with early shock or acute pancreatitis accompanied by dehydration, it is recommended to perform rapid fluid resuscitation in a short time
.
Give appropriate infusions to patients without dehydration
.
Early active intravenous fluids in the first 12 to 24 hours is the most beneficial
.
Liquid overload can have harmful effects, so the volume and speed of infusion should be adjusted dynamically with reference to hematocrit, blood urea nitrogen, creatinine and lactic acid levels
.
The first choice is isotonic crystal rehydration
.
Recommendation 7 AP patients should receive analgesic treatment within 24 hours after admission
.
There is no evidence or recommendation for any restrictions on pain medications
.
Acute kidney injury should avoid the use of non-steroidal anti-inflammatory drugs
.
In non-tracheal intubation patients, dihydromorphone hydrochloride has better analgesic effects than morphine or fentanyl
.
Recommendation 8 Routine preventive use of antibiotics is not recommended
.
For patients who show signs of sepsis or who have positive puncture culture of bacteria from infectious necrosis, they must use drug-sensitive antibiotics in time
.
Recommendation 9 For patients with infectious necrosis, antibiotics that can penetrate the necrotic pancreas should be selected, and the antibacterial spectrum should cover aerobic and anaerobic gram-negative and gram-positive bacteria
.
Quinolone and carbapenem drugs have good pancreatic tissue permeability and can cover anaerobes
.
Due to the high drug resistance rate, quinolones are generally only used for patients who are allergic to β-lactam drugs, and carbapenems are only used for critically ill patients
.
The third-generation cephalosporin has a moderate osmotic effect on pancreatic tissue
.
Piperacillin/tazobactam is effective against gram-positive bacteria and anaerobes
.
Recommendation 10 Early and adequate use of somatostatin and its analogues and protease inhibitors
.
Recommendation 11 Early oral eating (usually within 24 hours) should be tolerated instead of fasting
.
If the oral diet cannot be tolerated, enteral nutrition (EN) treatment should be started as soon as possible within 72 hours after admission
.
EN can be administered via a naso-gastric tube
.
In case of digestive intolerance, it is administered via a nasal-jejunal tube
.
For SAP patients, the nutritional support method should be determined based on intra-abdominal pressure and bowel function
.
Recommend element diet and whole protein diet
.
Recommendation 12 For AP patients with acute cholangitis or biliary obstruction, emergency endoscopic retrograde cholangiopancreatography (ERCP) or duodenal sphincterotomy (EST) should be performed within 24 hours of admission
.
Patients with biliary pancreatitis without obstructive jaundice or acute cholangitis do not need early ERCP
.
For patients who are highly suspected of having common bile duct stones without cholangitis or jaundice, MRCP or EUS is performed to confirm the diagnosis
.
Recommendation 13 To prevent post-ERCP pancreatitis, if there are no contraindications, NSAIDs should be administered rectally immediately before or after ERCP, and pancreatic duct stents should be placed in high-risk patients
.
Recommendation 14 For mild biliary pancreatitis with gallbladder stones, laparoscopic cholecystectomy should be performed during the current hospital stay
.
For severe acute biliary pancreatitis with peripancreatic effusion, surgery should be postponed for 6 weeks
.
Recommendation 15 A modified Marshall scoring system of 2 or more is defined as organ failure
.
When mechanically ventilated, a lung-protective ventilation strategy should be used
.
Severe acute pancreatitis (SAP) is treated with continuous renal replacement therapy (CRRT) for acute kidney injury
.
Recommendation 16 It is recommended to routinely measure intra-abdominal pressure (IAP) for patients with large amounts of fluids, SAP with renal and respiratory complications, and large amounts of abdominal effusion found on CT
.
When IAP≥12mmhg persists or recurs, the abdominal pressure should be controlled in time
.
When there is severe organ failure and conservative treatment is not effective for the patient, surgical decompression can be considered
.
Recommendation 17 For aseptic necrosis, if encapsulated necrosis causes gastrointestinal obstruction and bile duct obstruction after 4-8 weeks, intervention should be made
.
If the patient has persistent pain and “hyperplasia” of the necrotic cyst wall, it is recommended to intervene after 8 weeks
.
For infectious necrosis, the intervention is delayed until at least 4 weeks after the first appearance
.
The intervention method adopts a multidisciplinary minimally invasive method of ascending the ladder
.
Recommendation 18 The indications for surgical intervention include abdominal compartment syndrome, unsuccessful interventional therapy for acute persistent bleeding, intestinal ischemia or acute necrotizing cholecystitis, and intestinal fistula leading to peripancreatic fluid
.
Recommendation 19 The concept and method of integrated traditional Chinese and western medicine should be incorporated into comprehensive treatments such as abdominal abdominal surgery for patients with acute pancreatitis
.
Recommendation 20 The prevention of long-term complications of AP, such as recurrent pancreatitis, chronic pancreatitis, and diabetes, should be included in the entire diagnosis and treatment of acute pancreatitis
.
The above content is extracted from: Emergency Branch of Chinese Medical Association, Beijing-Tianjin-Hebei Emergency Medical Association, Emergency Branch of Beijing Medical Association, etc.
Expert consensus on acute pancreatitis emergency diagnosis and treatment[J].
Chinese Journal of Emergency Medicine, 2021,30(2): 161-172.
It is one of the common digestive system emergencies
.
The "Expert Consensus on the Emergency Diagnosis and Treatment of Acute Pancreatitis" aims to help emergency clinical medical staff quickly diagnose and evaluate the condition of AP, and provide standardized treatment in a timely manner, in order to reduce the incidence of later complications and surgical intervention rates, and shorten the length of hospitalization
.
Main recommendations Recommendations 1 The acute pancreatitis bedside severity index (BISAP) score is simple and easy to implement, with high accuracy.
Emergency physicians should complete the BISAP score within 24 hours of admission to early predict the severity of acute pancreatitis
.
Recommendation 2 Patients with persistent organ failure and infectious necrosis are at the highest risk of death
.
Recommendation 3 Use procalcitonin to detect pancreatic infections
.
C-reactive protein level ≥150 mg/L on day 3 can be used as a prognostic factor for severe acute pancreatitis
.
Hematocrit>44% is an independent risk factor for pancreatic necrosis
.
Blood urea nitrogen >20 mg/dL (7.
14 mmol/L) is an independent predictor of death
.
Recommendation 4 The best time for the first enhanced CT evaluation is 72~96h after the onset of disease
.
For critically ill patients, complete abdominal and pelvic enhanced CT and abdominal MRI + magnetic resonance cholangiopancreatography (MRCP) 48 to 72 hours after the onset of symptoms
.
For patients with signs of infection, significant deterioration in clinical status, and gastrointestinal obstruction or signs of infection with peripancreatic effusion for more than 4 weeks, the abdominal and pelvic enhanced CT and abdominal MRI+MRCP should be reviewed
.
MRCP or EUS is used to screen for occult choledocholithiasis
.
MRI helps to determine the status of pancreatic necrosis (sterile and infectious)
.
Recommendation 5 Emergency physicians should use multidisciplinary diagnosis and treatment concepts and models at the beginning of admission for AP patients.
The indication for transfer to the ICU is organ failure for more than 48 hours.
If fatal multi-organ failure occurs, they need to be transferred to the ICU in time
.
Recommendation 6 For patients with early shock or acute pancreatitis accompanied by dehydration, it is recommended to perform rapid fluid resuscitation in a short time
.
Give appropriate infusions to patients without dehydration
.
Early active intravenous fluids in the first 12 to 24 hours is the most beneficial
.
Liquid overload can have harmful effects, so the volume and speed of infusion should be adjusted dynamically with reference to hematocrit, blood urea nitrogen, creatinine and lactic acid levels
.
The first choice is isotonic crystal rehydration
.
Recommendation 7 AP patients should receive analgesic treatment within 24 hours after admission
.
There is no evidence or recommendation for any restrictions on pain medications
.
Acute kidney injury should avoid the use of non-steroidal anti-inflammatory drugs
.
In non-tracheal intubation patients, dihydromorphone hydrochloride has better analgesic effects than morphine or fentanyl
.
Recommendation 8 Routine preventive use of antibiotics is not recommended
.
For patients who show signs of sepsis or who have positive puncture culture of bacteria from infectious necrosis, they must use drug-sensitive antibiotics in time
.
Recommendation 9 For patients with infectious necrosis, antibiotics that can penetrate the necrotic pancreas should be selected, and the antibacterial spectrum should cover aerobic and anaerobic gram-negative and gram-positive bacteria
.
Quinolone and carbapenem drugs have good pancreatic tissue permeability and can cover anaerobes
.
Due to the high drug resistance rate, quinolones are generally only used for patients who are allergic to β-lactam drugs, and carbapenems are only used for critically ill patients
.
The third-generation cephalosporin has a moderate osmotic effect on pancreatic tissue
.
Piperacillin/tazobactam is effective against gram-positive bacteria and anaerobes
.
Recommendation 10 Early and adequate use of somatostatin and its analogues and protease inhibitors
.
Recommendation 11 Early oral eating (usually within 24 hours) should be tolerated instead of fasting
.
If the oral diet cannot be tolerated, enteral nutrition (EN) treatment should be started as soon as possible within 72 hours after admission
.
EN can be administered via a naso-gastric tube
.
In case of digestive intolerance, it is administered via a nasal-jejunal tube
.
For SAP patients, the nutritional support method should be determined based on intra-abdominal pressure and bowel function
.
Recommend element diet and whole protein diet
.
Recommendation 12 For AP patients with acute cholangitis or biliary obstruction, emergency endoscopic retrograde cholangiopancreatography (ERCP) or duodenal sphincterotomy (EST) should be performed within 24 hours of admission
.
Patients with biliary pancreatitis without obstructive jaundice or acute cholangitis do not need early ERCP
.
For patients who are highly suspected of having common bile duct stones without cholangitis or jaundice, MRCP or EUS is performed to confirm the diagnosis
.
Recommendation 13 To prevent post-ERCP pancreatitis, if there are no contraindications, NSAIDs should be administered rectally immediately before or after ERCP, and pancreatic duct stents should be placed in high-risk patients
.
Recommendation 14 For mild biliary pancreatitis with gallbladder stones, laparoscopic cholecystectomy should be performed during the current hospital stay
.
For severe acute biliary pancreatitis with peripancreatic effusion, surgery should be postponed for 6 weeks
.
Recommendation 15 A modified Marshall scoring system of 2 or more is defined as organ failure
.
When mechanically ventilated, a lung-protective ventilation strategy should be used
.
Severe acute pancreatitis (SAP) is treated with continuous renal replacement therapy (CRRT) for acute kidney injury
.
Recommendation 16 It is recommended to routinely measure intra-abdominal pressure (IAP) for patients with large amounts of fluids, SAP with renal and respiratory complications, and large amounts of abdominal effusion found on CT
.
When IAP≥12mmhg persists or recurs, the abdominal pressure should be controlled in time
.
When there is severe organ failure and conservative treatment is not effective for the patient, surgical decompression can be considered
.
Recommendation 17 For aseptic necrosis, if encapsulated necrosis causes gastrointestinal obstruction and bile duct obstruction after 4-8 weeks, intervention should be made
.
If the patient has persistent pain and “hyperplasia” of the necrotic cyst wall, it is recommended to intervene after 8 weeks
.
For infectious necrosis, the intervention is delayed until at least 4 weeks after the first appearance
.
The intervention method adopts a multidisciplinary minimally invasive method of ascending the ladder
.
Recommendation 18 The indications for surgical intervention include abdominal compartment syndrome, unsuccessful interventional therapy for acute persistent bleeding, intestinal ischemia or acute necrotizing cholecystitis, and intestinal fistula leading to peripancreatic fluid
.
Recommendation 19 The concept and method of integrated traditional Chinese and western medicine should be incorporated into comprehensive treatments such as abdominal abdominal surgery for patients with acute pancreatitis
.
Recommendation 20 The prevention of long-term complications of AP, such as recurrent pancreatitis, chronic pancreatitis, and diabetes, should be included in the entire diagnosis and treatment of acute pancreatitis
.
The above content is extracted from: Emergency Branch of Chinese Medical Association, Beijing-Tianjin-Hebei Emergency Medical Association, Emergency Branch of Beijing Medical Association, etc.
Expert consensus on acute pancreatitis emergency diagnosis and treatment[J].
Chinese Journal of Emergency Medicine, 2021,30(2): 161-172.
