ASGE Annual GI Advanced Practice Provider Course (Virtual) (Day Two) | March 2026-Pancreatitis: Comprehensive Management of Acute and Chronic Cases

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This presentation reviews evidence-based management of acute pancreatitis (AP) and chronic pancreatitis (CP), emphasizing practical diagnosis, supportive care, complication management, and treatment of exocrine pancreatic insufficiency (EPI).<br /><br />AP is an inflammatory pancreatic disorder and a leading GI cause of hospitalization in the U.S., with rising incidence but little improvement in outcomes. The most common etiologies are gallstones and alcohol; others include post-ERCP, medications (rare), hypertriglyceridemia, autoimmune disease, hypercalcemia, anatomic variants, tumors, and idiopathic cases. Diagnosis follows the Revised Atlanta Criteria: at least 2 of 3—typical abdominal pain, lipase/amylase ≥3× ULN, or characteristic imaging findings. Initial evaluation includes labs to assess etiology and severity (LFTs, triglycerides, calcium, IgG4, BUN/Cr, CBC) and targeted imaging (ultrasound for biliary disease; CT only for specific indications). Severity ranges from mild (no organ failure) to severe (persistent organ failure).<br /><br />Core AP treatment is hospital admission, NPO initially, analgesia/antiemetics, and close monitoring with goal-directed IV fluids; aggressive fluid resuscitation increases fluid overload without outcome benefit (WATERFALL trial). Early enteral nutrition is important—often within 48 hours in mild disease and within a week in severe disease (NJ feeding preferred when needed). Prophylactic antibiotics are not recommended; use only for cholangitis/biliary sepsis or proven/suspected infection. ERCP is reserved for cholangitis, documented CBD stones, or duct leaks—not routinely for all cases. In gallstone pancreatitis, same-admission cholecystectomy is preferred when feasible.<br /><br />Complications of AP include pseudocysts, necrosis, organ failure, obstruction, pleural effusion, fistulas, and malnutrition. Asymptomatic pseudocysts can be observed; symptomatic or infected collections are managed with a step-up drainage approach (endoscopic/percutaneous/surgical).<br /><br />CP is a progressive fibroinflammatory syndrome (TIGAR-O causes). Diagnosis relies on CT/MRI/MRCP, EUS (including Rosemont criteria), and pancreatic function tests. Management is multidisciplinary: alcohol/tobacco cessation, nutrition support, pain strategies (WHO ladder, neuromodulators, CBT, celiac plexus block), endoscopic therapy for ductal disease, and surgery for refractory pain, obstruction, or malignancy concern. EPI is common in advanced CP; diagnose with fecal elastase or clinically, and treat with appropriately dosed pancreatic enzyme replacement therapy (PERT), optimizing timing, dose, and acid suppression when needed. CP increases pancreatic cancer risk, but routine screening is not recommended without genetic/family risk.

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Sarah Enslin, PA-C

Keywords

acute pancreatitis

chronic pancreatitis

Revised Atlanta Criteria

goal-directed IV fluid resuscitation

early enteral nutrition

gallstone pancreatitis

ERCP indications

pancreatic pseudocyst and necrosis step-up drainage

exocrine pancreatic insufficiency (EPI)

pancreatic enzyme replacement therapy (PERT)