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New AGA guideline steers early treatment for acute pancreatitis
A new clinical guideline from the American Gastroenterological Association provides up-to-date recommendations for early treatment decisions in acute pancreatitis.
Aiming to promote consistent practices and quality care, the new guideline focuses on clinical decisions made within the first 48 to 72 hours of hospital admission for acute pancreatitis, which can “alter the course of disease and duration of hospitalization.” It includes recommendations on goal-directed fluid resuscitation, early oral feeding, enteral vs. parenteral nutrition, routine prophylactic antibiotic use and routine endoscopic retrograde cholangiopancreatography (ERCP).
According to the guideline committee, acute pancreatitis is a leading gastrointestinal cause of inpatient care. More than 275,000 patients are hospitalized per year costing more than $2.6 billion in the U.S., and evidence suggests incidence is on the rise.
The guideline issued four “strong” recommendations based on moderate quality evidence, including:
- Oral feeding should be given within 24 hours as tolerated rather than following the “nothing by mouth” or nil per os (NPO) practice;
- Enteral rather than parenteral nutrition should be used in patients who are unable to feed orally;
- Cholecystectomy should be performed at initial admission in patients with acute biliary pancreatitis, rather than after they are discharged; and
- A brief alcohol intervention should be performed during admission in patients with acute alcohol-induced pancreatitis.
“I suspect the recommendations that will get the most attention are those dealing with nutrition, particularly the recommendation to initiate early PO intake,” guideline co-author Seth D. Crockett, MD, MPH, assistant professor of gastroenterology and hepatology at University of North Carolina, told Healio Gastroenterology and Liver Disease. “This goes contrary to what many of us learned in med school and residency about the ‘NPO and bowel rest’ strategy for patients with [acute pancreatitis]. Another one that may generate discussion is the recommendation to perform a cholecystectomy in patients with gallstone pancreatitis during the index admission, vs. a subsequent outpatient surgery. There is good evidence that this improves outcomes and is just as safe for patients, but it’s often not done.”
Other “conditional” recommendations based on lower quality evidence include:
- Goal-directed therapy for fluid management should be used; while the committee did not offer a recommendation on whether normal saline or ringer’s lactate should be used, they did suggest against the use of hydroxyethyl starch (HES) fluids;
- Prophylactic antibiotics should not be used in patients with predicted severe or necrotizing acute pancreatitis;
- Routine use of urgent ERCP should not be used in patients with acute biliary pancreatitis without accompanying cholangitis; and
- Either the nasogastric or nasoenteral route should be used for enteral tube feeding if required by patients with predicted severe or necrotizing acute pancreatitis.
The recommendation regarding nasogastric vs. nasoduodenal or nasojejunal tubes “may surprise some folks,” Crockett said. “Some consider it dogma that enteral feeding tubes must extend beyond the ampulla in [acute pancreatitis], but there is little evidence that this actually influences important patient outcomes.”
The guideline committee concluded that “current evidence supports the benefit of goal-directed fluid resuscitation, early oral feeding, and enteral rather than parenteral nutrition, in all patients with [acute pancreatitis]. Our evidence profiles also support the benefit of same-admission cholecystectomy for patients with biliary pancreatitis, and brief alcohol intervention for patients with alcohol-induced pancreatitis. In contrast, current evidence does not support a benefit for the routine use of prophylactic antibiotics in predicted severe [acute pancreatitis] or routine ERCP in patients with [acute pancreatitis] without accompanying cholangitis.
The committee noted that research gaps requiring additional study include the optimal fluid therapy practice in acute pancreatitis, quantified benefits and harms of goal-directed therapy vs. other approaches, the benefits of Ringer’s lactate solution vs. normal saline, risk-stratification, antibiotic prophylaxis in patient subgroups, timing of ERCP in certain patients, and the impacts of alcohol and tobacco cessation.
The guideline is accompanied by a technical review outlining the evidence supporting the guideline committee’s recommendations. – by Adam Leitenberger
Disclosures: The authors report no relevant financial disclosures.
Editor's note: This article was updated on Feb. 16 with additional information from a guideline co-author.