Introduction
Methods
Grade of recommendation | Clarity of risk/benefit | Quality of supporting evidence | Implications |
---|---|---|---|
1A | |||
Strong recommendation, high-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | RCTs without important limitations or overwhelming evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1B | |||
Strong recommendation, moderate-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | RCTs with important limitations (inconsistent results, methodological flaws, indirect analyses or imprecise conclusions) or exceptionally strong evidence from observational studies | Strong recommendation, applies to most patients in most circumstances without reservation |
1C | |||
Strong recommendation, low-quality or very low-quality evidence | Benefits clearly outweigh risk and burdens, or vice versa | Observational studies or case series | Strong recommendation but subject to change when higher quality evidence becomes available |
2A | |||
Weak recommendation, high-quality evidence | Benefits closely balanced with risks and burden | RCTs without important limitations or overwhelming evidence from observational studies | Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values |
2B | |||
Weak recommendation, moderate-quality evidence | Benefits closely balanced with risks and burden | RCTs with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies | Weak recommendation, best action may differ depending on the patient, treatment circumstances, or social values |
2C | |||
Weak recommendation, Low-quality or very low-quality evidence | Uncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balanced | Observational studies or case series | Very weak recommendation; alternative treatments may be equally reasonable and merit consideration |
Results
Diagnosis
Statements (severity grading)
Revised Atlanta Classification (RAC) | Determinant-based classification (DBC |
---|---|
Mild acute pancreatitis (AP) | Mild AP |
No organ failure | No organ failure AND |
No local or systemic complications | No (peri)pancreatic necrosis |
Moderately severe AP | Moderate AP |
Transient organ failure (< 48 h) | Transient organ failure AND/OR |
Local or systemic complications without persistent organ failure | Sterile (peri)pancreatic necrosis |
Severe AP | Severe AP |
Persistent single or multiple organ | Persistent organ failure OR |
failure (> 48 h) | Infected (peri)pancreatic necrosis |
Critical AP | |
Persistent organ failure AND | |
Infected (peri)pancreatic necrosis |
Statements (imaging)
CT grade | Grade score | Definition |
A | 0 | Normal pancreas |
B | 1 | Pancreatic enlargement |
C | 2 | Pancreatic inflammation and/or peripancreatic fat |
D | 3 | Single peripancreatic fluid collection |
E | 4 | ≥ 2 fluid collections and/or retroperitoneal air |
% of necrosis | Necrosis score | Definition |
None | 0 | Uniform pancreatic enhancement |
< 30% | 2 | Non-enhancement of region(s) of gland equivalent in size of pancreatic head |
30–50% | 4 | Non-enhancement of 30–50% of the gland |
> 50% | 6 | Non-enhancement of over 50% of the gland |
CT Severity Index | Morbidity | Mortality |
0–1 | 0 | 0 |
2–3 | 8% | 3% |
4–6 | 35% | 6% |
7–10 | 92% | 17% |
Statements (diagnostic laboratory parameters)
Statements (diagnostics in idiopathic pancreatitis)
Statement (risk scores)
BISAP: score one point for each of the following criteria | |
---|---|
Blood urea nitrogen level > 8.9 mmol/L | |
Impaired mental status | |
Systemic inflammatory response syndrome is present | |
Age > 60 years | |
Pleural effusion on radiography |
Statements (follow-up imaging)
Antibiotic treatment
Statement (prophylactic antibiotics)
Statement (infected necrosis and antibiotics)
Statement (type of antibiotics)
Intensive care unit
Statement (monitoring)
Statement (fluid resuscitation)
Statement (pain control)
Statement (mechanical ventilation)
Statement (increased intra-abdominal pressure)
Statement (pharmacological treatment)
Statement (enteral nutrition)
Surgical and operative management
Statements (indications for emergent ERCP)
Statement (indications for percutaneous/endoscopic drainage of pancreatic collections)
-
On-going organ failure without sign of infected necrosis
-
On-going gastric outlet, biliary, or intestinal obstruction due to a large walled off necrotic collection
-
Disconnected duct syndrome
-
Symptomatic or growing pseudocyst
-
On-going pain and/or discomfort
Statements (indications for surgical intervention)
-
As a continuum in a step-up approach after percutaneous/endoscopic procedure with the same indications
-
Abdominal compartment syndrome
-
Acute on-going bleeding when endovascular approach is unsuccessful
-
Bowel ischaemia or acute necrotizing cholecystitis during acute pancreatitis
-
Bowel fistula extending into a peripancreatic collection