The diagnosis of
acute pancreatitis is based on the following findings: (1) acute attacks of
abdominal pain and tenderness in the epigastric region, (2) elevated blood levels of pancreatic
enzymes, and (3) abnormal diagnostic imaging findings in the pancreas associated with
acute pancreatitis. In Japan, in accordance with criteria established by the Japanese Ministry of Health, Labour, and Welfare, the severity of
acute pancreatitis is assessed based on the clinical signs, hematological findings, and imaging findings, including abdominal contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). Severity must be re-evaluated, especially in the period 24 to 48 h after the onset of
acute pancreatitis, because even cases diagnosed as mild or moderate in the early stage may rapidly progress to severe. Management is selected according to the severity of
acute pancreatitis, but it is imperative that an adequate infusion volume, vital-sign monitoring, and
pain relief be instituted immediately after diagnosis in every patient. Patients with severe cases are treated with broad-spectrum
antimicrobial agents, a continuous high-dose
protease inhibitor, and continuous
intraarterial infusion of
protease inhibitors and
antimicrobial agents; continuous
hemodiafiltration may also be used to manage patients with severe cases. Whenever possible, transjejunal
enteral nutrition should be administered, even in patients with severe cases, because it seems to decrease morbidity. Necrosectomy is performed when necrotizing
pancreatitis is complicated by
infection. In this case, continuous closed lavage or open drainage (planned necrosectomy) should be the selected procedure. Pancreatic
abscesses are treated by surgical or percutaneous drainage. Emergency endoscopic procedures are given priority over other methods of management in patients with acute
gallstone-associated
pancreatitis, patients suspected of having
bile duct obstruction, and patients with acute
gallstone pancreatitis complicated by
cholangitis. These strategies for the management of
acute pancreatitis are shown in the algorithm in this article.