Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review

Recent advances in understanding and managing acute pancreatitis

“…Two recent guidelines affirmed the importance of predicting the severity of AP, using one or more predictive tools 2, 5 . The recent 2018 AGA technical review does not debate this common-sense approach, including use of dynamic predictive variables over time, but does highlight that there is no published observational study or randomized controlled trial (RCT) investigating whether the use of severity prediction tools impacts clinical outcomes 3 .…”

“…This limitation, particularly in older literature, served as the impetus for the 2012 revision of the Atlanta Criteria for AP 53 . To extract from the literature meaningful summary evidence and estimates for the AGA Clinical Guideline on early medical management of AP, the 2018 AGA technical review applied precise definitions to each step of the review process, and the emphasis was on clear definitions of primary outcomes of clinical importance in AP, including death, persistent single organ failure (PSOF), or persistent multiple organ failure (PMOF), each requiring a duration of more than 48 hours, and infected pancreatic or peri-pancreatic necrosis or both 3, 4 . For these reasons, our review of early treatment of AP preferentially weighs recommendations in favor of those espoused by the 2018 AGA technical review and clinical guideline.…”

“…Hypovolemia in AP is driven by third spacing and intravascular volume depletion 64 . Guidelines advocate for early fluid resuscitation to correct intravascular depletion in order to reduce morbidity and mortality associated with AP 2, 3, 5 . However, as Haydock et al point out, there is a deficiency of high-quality data to establish firm recommendations 65 .…”

“…The 2018 AGA guidelines endorse a conditional recommendation for using goal-directed therapy for initial fluid management 4 , do not recommend for or against normal saline versus lactated Ringer’s (LR), but do advise against the use of hydroxyethyl starch fluids 4 . The AGA guidelines and the technical review acknowledge that evidence was weak in support of goal-directed therapy 3, 4 , which was a pre-defined study arm in four of seven RCTs reviewed and had no significant reduction in PMOF, mortality, or pancreatic necrosis compared with usual care. As the authors noted, interpretation of the data was limited by the absence of other critical outcomes in these trials (infected pancreatic necrosis), lack of uniformity of specific outcomes and definitions of transient and POF, few trials, and risk of bias.…”

“…In 2012, AP was the single most common specific gastrointestinal diagnosis for inpatient hospitalization, and annual costs were about $2.6 billion 1 . Several major clinical guidelines provide evidence-based recommendations for the clinical management decisions in AP, including those from the American College of Gastroenterology (ACG) (2013) 2 , the American Gastroenterological Association (AGA) (2018) 3, 4 , and the International Association of Pancreatology (IAP) (2013) 5 . In this update on AP, we reference recent literature and guideline recommendations focused on epidemiology, risk factors, etiology, diagnosis, risk stratification, and recent advances in the early medical management of AP.…”