Acute pancreatitis...American college of GI 2013 recs

Diagnosis
1.	The diagnosis of AP is most often established by the presence of two of the three following criteria: (i) abdominal pain consistent with the disease, (ii) serum amylase and/or lipase greater than three times the upper limit of normal, and/or (iii) characteristic findings from abdominal imaging (strong recommendation, moderate quality of evidence).
2.	Contrast-enhanced computed tomographic (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first 48–72 h after hospital admission (strong recommendation, low quality of evidence).
Etiology
3.	Transabdominal ultrasound should be performed in all patients with acute pancreatitis (strong recommendation, low quality of evidence).
4.	In the absence of gallstones and/or history of significant history of alcohol use, a serum triglyceride should be obtained and considered the etiology if >1,000mg/dl (conditional recommendation, moderate quality of evidence).
5.	In a patient older than 40 years, a pancreatic tumor should be considered as a possible cause of acute pancreatitis (conditional recommendation, low quality of evidence).
6.	Endoscopic investigation in patients with acute idiopathic pancreatitis should be limited, as the risks and benefits of investigation in these patients are unclear (conditional recommendation, low quality of evidence).
7.	Patients with idiopathic pancreatitis should be referred to centers of expertise (conditional recommendation, low quality of evidence).
8.	Genetic testing may be considered in young patients ( < 30 years old) if no cause is evident and a family history of pancreatic disease is present (conditional recommendation, low quality of evidence).
Initial assessment and risk stratification
9.	Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed (strong recommendation, moderate quality of evidence).
10.	Risk assessment should be performed to stratify patients into higher- and lower-risk categories to assist triage, such as admission to an intensive care setting (conditional recommendation, moderate quality of evidence).
11.	Patients with organ failure should be admitted to an intensive care unit or intermediary care setting whenever possible (strong recommendation, low quality of evidence).
Initial management
12.	Aggressive hydration, defined as 250-500 ml per hour of isotonic crystalloid solution should be provided to all patients, unless cardiovascular and/or renal comorbidites exist. Early aggressive intravenous hydration is most beneficial the first 12–24 h, and may have little benefit beyond (strong recommendation, moderate quality of evidence).
13.	In a patient with severe volume depletion, manifest as hypotension and tachycardia, more rapid repletion (bolus) may be needed (conditional recommendation, moderate quality of evidence).
14.	Lactated Ringer’s solution may be the preferred isotonic crystalloid replacement fluid (conditional recommendation, moderate quality of evidence).
15.	Fluid requirements should be reassessed at frequent intervals within 6 h of admission and for the next 24–48 h. The goal of aggressive hydration should be to decrease the blood urea nitrogen (strong recommendation, moderate quality of evidence).
ERCP in acute pancreatitis
16.	Patients with acute pancreatitis and concurrent acute cholangitis should undergo ERCP within 24 h of admission (strong recommendation, moderate quality of evidence).
17.	ERCP is not needed in most patients with gallstone pancreatitis who lack laboratory or clinical evidence of ongoing biliary obstruction (strong recommendation, low quality of evidence).
18.	In the absence of cholangitis and/or jaundice, MRCP or endoscopic ultrasound (EUS) rather than diagnostic ERCP should be used to screen for choledocholithiasis if highly suspected (conditional recommendation, low quality of evidence).
19.	Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to prevent severe post-ERCP pancreatitis in high-risk patients (conditional recommendation, moderate quality of evidence).
The role of antibiotics in acute pancreatitis
20.	Antibiotics should be given for an extrapancreatic infection, such as cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia (strong recommendation, high quality of evidence).
21.	Routine use of prophylactic antibiotics in patients with severe acute pancreatitis is not recommended (strong recommendation, moderate quality of evidence).
22.	The use of antibiotics in patients with sterile necrosis to prevent the development of infected necrosis is not recommended (strong recommendation, moderate quality of evidence).
23.	Infected necrosis should be considered in patients with pancreatic or extrapancreatic necrosis who deteriorate or fail to improve after 7–10 days of hospitalization. In these patients, either (i) initial CT-guided fine needle aspiration (FNA) for Gram stain and culture to guide use of appropriate antibiotics or (ii) empiric use of antibiotics without CT FNA should be given (strong recommendation, low quality of evidence).