J Hepatobiliary Pancreat Surg (2006) 13:61–67DOI 10.1007/s00534-005-1053-5

Management strategy for acute pancreatitis in the JPN Guidelines

Toshihiko Mayumi1, Tadahiro Takada2,*, Yoshifumi Kawarada3, Koichi Hirata4, Masahiro Yoshida2,Miho Sekimoto5, Masahiko Hirota6, Yasutoshi Kimura4, Kazunori Takeda7, Shuji Isaji8, Masaru Koizumi9,Makoto Otsuki10,**, and Seiki Matsuno11,***

1 Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku,Nagoya 466-8560, Japan2 Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan3 Ueno Municipal Hospital, Mie, Japan4 First Department of Surgery, Sapporo Medical University School of Medicine, Hokkaido, Japan5 Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan6 Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan7 Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan8 Department of Hepatobiliary Pancreatic Surgery and Breast Surgery, Mie University Graduate School of Medicine, Mie, Japan9 Ohara Medical Center Hospital, Fukushima, Japan10 Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, School of Medicine,Kitakyushu, Japan11 Division of Gastroenterological Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan

cases, because it seems to decrease morbidity. Necrosectomyis performed when necrotizing pancreatitis is complicatedby infection. In this case, continuous closed lavage or opendrainage (planned necrosectomy) should be the selected pro-cedure. Pancreatic abscesses are treated by surgical or percu-taneous drainage. Emergency endoscopic procedures aregiven priority over other methods of management in patientswith acute gallstone-associated pancreatitis, patients sus-pected of having bile duct obstruction, and patients with acutegallstone pancreatitis complicated by cholangitis. These strat-egies for the management of acute pancreatitis are shown inthe algorithm in this article.

Key words Acute pancreatitis · Algorithm · Guidelines ·Decision-making · Evidence-based medicine

Clinical questions

CQ1. How is acute pancreatitis diagnosed?CQ2. What is the basic initial management of

acute pancreatitis?CQ3. Is an evaluation of the etiology of acute

pancreatitis necessary in the initialmanagement?

CQ4. Why is a severity assessment of acutepancreatitis necessary in the initialmanagement?

CQ5. When should patients with acute pancreati-tis be transferred to a specialist hospital?

CQ6. Why are contrast-enhanced CT scanningand MRI used in the management of acutepancreatitis?

Abstract The diagnosis of acute pancreatitis is based on thefollowing findings: (1) acute attacks of abdominal pain andtenderness in the epigastric region, (2) elevated blood levelsof pancreatic enzymes, and (3) abnormal diagnostic imagingfindings in the pancreas associated with acute pancreatitis. InJapan, in accordance with criteria established by the JapaneseMinistry of Health, Labour, and Welfare, the severity of acutepancreatitis is assessed based on the clinical signs, hematologi-cal findings, and imaging findings, including abdominal con-trast-enhanced computed tomography (CT) and magneticresonance imaging (MRI). Severity must be re-evaluated, es-pecially in the period 24 to 48h after the onset of acute pancre-atitis, because even cases diagnosed as mild or moderate in theearly stage may rapidly progress to severe. Management isselected according to the severity of acute pancreatitis, but it isimperative that an adequate infusion volume, vital-sign moni-toring, and pain relief be instituted immediately after diagno-sis in every patient. Patients with severe cases are treated withbroad-spectrum antimicrobial agents, a continuous high-doseprotease inhibitor, and continuous intraarterial infusion ofprotease inhibitors and antimicrobial agents; continuoushemodiafiltration may also be used to manage patients withsevere cases. Whenever possible, transjejunal enteral nutri-tion should be administered, even in patients with severe

Offprint requests to: T. Mayumi*President, Japanese Society of Emergency AbdominalMedicine; President, Japanese Society of Hepato-Biliary-Pancreatic Surgery; President, Asian-PacificHepato-Pancreato-Biliary Association**Chairman, Intractable Pancreatic Disease Investiga-tion and Research Group of the Japanese Ministry ofHealth, Labour, and Welfare***President, Japan Pancreas Society

62 T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines

CQ7. What is important in the critical care ofsevere acute pancreatitis?

CQ8. What are some optional therapies for severeacute pancreatitis?

CQ9. How can the complications of acute pancre-atitis be assessed?

CQ10. Is the endoscopic approach beneficial inthe treatment of acute gallstone-inducedpancreatitis?

CQ11. Is one-stage cholecystectomy followed bycommon bile duct (CBD) clearance saferand more effective than endoscopicprocedures?

CQ12. When should laparoscopic cholecystectomybe undertaken in patients with gallstonepancreatitis?

Basic medical treatment policy (see flowchart in Fig. 1)

Evidence-based clinical practice guidelines for acutepancreatitis were created a few years ago,1 but severalmodifications have been made, thanks to consensusconferences and a great deal of feedback. The flowchartin Fig. 1 illustrates the details of the current Guidelinesaccording to the procedures and the timing of theirperformance. A brief explanation of each point is pro-vided in this article, but please refer to the correspond-ing text in the Guidelines for details.2–9

Fig. 1. Basic treatment policy. CT, computed tomography

T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines 63

Diagnosis of acute pancreatitis5

Clinical question (CQ) 1. How is acute pancreatitisdiagnosed?

Acute pancreatitis is diagnosed based on acomprehensive assessment of the clinical manifesta-tions, including elevated extrapancreatic enzyme levelsand imaging findings in the pancreas (Recommenda-tion A).

In 1990, the Research Group for Intractable Diseasesand Refractory Pancreatic Diseases, which was spon-sored by the then Japanese Ministry of Health andWelfare, established the criteria for diagnosing acutepancreatitis in Japan (Table 1), and these criteria havebeen used as the gold standard ever since. Acute pan-creatitis must be differentiated from other conditions.Acute abdomen, gastrointestinal perforation, acutecholecystitis, ileus, mesenteric artery occlusion, andacute aortic dissection must all be ruled out.

Basic management7

CQ2. What is the basic initial management of acutepancreatitis?

Adequate fluid infusion (Recommendation A), vital-sign monitoring, and respiratory and cardiovascularmanagement should be performed in the early stage,immediately after diagnosis is made. Research done inJapan in 2004 reported the infusion volume on the firstday in hospital to be less than 3500ml in 41 (61.2%) of 67patients who later died. An adequate infusion volumeshould be given in the early stage, because some casesdiagnosed initially as mild can rapidly progress to severe.

Pain relief with analgesics is necessary in patients withacute pancreatitis with associated pain, because the painmay cause mental distress and adversely impact the courseof treatment by, for example, causing tachypnea. Gastricsuction with a nasogastric tube (Recommendation D) isunnecessary in mild or moderate cases, unless acutepancreatitis is associated with paralytic ileus or frequentnausea/vomiting. H2 blockers are also unnecessary unlessa stress ulcer develops (Recommendation D).

Identification of etiological factors in acute pancreatitis5

CQ3. Is an evaluation of the etiology of acute pan-creatitis necessary in initial management?

Etiological factors in acute pancreatitis should beidentified promptly and accurately, because, togetherwith the severity assessment, they have a major impacton the treatment policy. It is particularly important todifferentiate acute gallstone-associated pancreatitisfrom acute alcoholic pancreatitis, because the twomanifestations require different management proce-dures, with the former including management of thebile duct system (Recommendation A)

Because different types of acute pancreatitis have dif-ferent treatments, each patient should be evaluated im-mediately for the presence of the following abnormalfindings related to etiology: leaking hepatic enzymes(alanine aminotransferase [ALT] and aspartate amino-transferase [AST]) and biliary system enzymes (alkalinephosphatase [ALP], lactate dehydrogerase [LDH], andguanosine triphosphate [GTP]), investigated usingblood biochemistry studies; and cholecystocholedocho-lithiasis and cholangiectasis, investigated using ultra-sonography (US) examination. Biliary sand and finegallbladder stones may be found later, even in patientsin whom cholecystocholedocholithiasis is not detectablein the acute stage. Therefore, patients should be repeat-edly examined for cholecystocholedocholithiasis, evenafter the acute stage.

Assessment of the severity of acute pancreatitis6

CQ4. Why is a severity assessment of acute pancre-atitis necessary in the initial management?

Severity assessment ensures appropriate management(Recommendation A). Because mild acute pancreatitisin the early stage may rapidly progress to severe pan-creatitis, continuous evaluation is necessary, particu-larly within the first 3 days of onset

Severity assessment according to severity scoring sys-tems (JPN score, Acute Physiology and Chronic Health

Table 1. Criteria for the clinical diagnosis of acute pancreatitisa

1. Attack of acute abdominal pain and tenderness in the upper abdomen2. Increased levels of pancreatic enzymes in blood, urine, or ascitesb

3. Abnormal imaging findings in pancreas associated with acute pancreatitis

Patients having two or more of the above three criteria are diagnosed with acute pancreatitis,excluding other pancreatic diseases and acute abdomen. However, an acute episode of chronicpancreatitis is diagnosed as acute pancreatitis. Cases confirmed as acute pancreatitis by surgery orautopsy should carry a supplement notea Research Group for Intractable Diseases and Refractory Pancreatic Diseases sponsored by thetheir Japanese Ministry of Health and Welfare in 1990b Measurement of highly specific pancreatic enzymes (such as P-amylase) is recommended

64 T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines

Evaluation [APACHE] II score) is important in decid-ing treatment policy and judging whether transfer to aspecialist unit is necessary (Recommendation A). Se-verity assessment on the basis of the JPN score is recom-mended in Japan.

Diagnosis of acute pancreatitis should be followed bya severity assessment and a management strategy ap-propriate to the level of severity. The Japanese criteriaand scoring system allow sequential scoring and areuseful for deciding on treatment policy. Use of this sys-tem has improved the survival rate.

Because even mild to moderate cases may progressto severe during the early stage, particularly within72 h of onset, severity should be re-evaluated within24 to 48 h of onset and again within 48 to 72 h ofonset.

The outcome for patients whose acute pancreatitisprogressed from mild or moderate to severe was foundto be poor in a Japanese study done in 2004.

Transfer to advanced specialist medical institutions6

CQ5. When should patients with acute pancreatitisbe transferred to a specialist hospital?

A JNP score of 2 or more is the criterion for transfer(Recommendation A). It is desirable to transfer pa-tients with severe acute pancreatitis to a medical insti-tution where monitoring and systemic management areavailable

In principle, acute pancreatitis should be treated on aninpatient basis. The criteria for evaluating the severityof acute pancreatitis established by the Japanese Minis-try of Health, Labour, and Welfare6 (JMHLW Criteria)have been used widely in Japan to assess the severity ofacute pancreatitis. It is desirable to transfer patientsdiagnosed with severe pancreatitis, based on these crite-ria, to a medical institution with fulltime surgeons andphysicians specializing in gastroenterology. In view oftheir significantly higher mortality rate, it has been re-ported (Level 3b) [89] that patients with a severity scoreof 8 or more according to the JMHLW Criteria or anAPACHE II score of 13 or more within the first 24 to48 h after onset should be transferred, preferably to aninstitution where they can be cared for by fulltime phy-sicians who specialize in intensive care, endoscopictreatment, radiological intervention, and cholangio-pancreatic surgery. Patients with cases diagnosed asmoderate also need to receive an adequate volume offluid infusion, meticulous monitoring of their clinicalcourse, and assessment of indications for transfer toadvanced medical institutions, because their acutepancreatitis may progress to severe pancreatitis. Thedecision to transfer a patient should be made carefully,

taking into consideration the potential impact of a longtrip on the patient’s condition.

It is desirable to transfer a patient with severe acutepancreatitis (JMHLW criteria severity score of 2 ormore) to a medical institution where monitoring andsystemic management are available and where the pa-tient will receive an adequate medical examination.

Contrast-enhanced computed tomography (CT)5,7

CQ6. Why are contrast-enhanced CT scanning andmagnetic resonance imaging (MRI) used in the man-agement of acute pancreatitis?

Contrast-enhanced CT scanning and magnetic reso-nance imaging (MRI) are essential for severity assess-ment and for making decisions about managementpolicy (Recommendation A).

The presence and extent of pancreatic necrosis and theextent of inflammatory change are correlated withseverity. Contrast-enhanced CT or contrast-enhancedMRI is required to make a definite judgment regardingthe presence and extent of pancreatic necrosis. How-ever, it should be noted that contrast media may causeadverse reactions.

The presence of pancreatic necrosis and the extent ofinflammatory change are closely correlated with variouscomplications and the mortality rate (Levels 1b–3b)[57–59] and may influence the selection of managementmethods, including the administration of prophylacticantimicrobial agents and intraarterial infusion therapy.Inflammatory change in the peripancreatic tissue can beevaluated by plain CT, but, because it is usually difficultto diagnose pancreatic necrosis, contrast-enhanced CTscanning (Level 1c) [60] is required to identify anddetermine the extent of pancreatic necrosis. However,while one study has shown that the use of contrast me-dium does not exacerbate the pathological conditions ofpancreatitis (Level 2b) [61], another has shown that itsuse exacerbates pancreatitis (Level 2b) [62] and that theuse of contrast medium may also exacerbate nephropa-thy, thereby complicating severe acute pancreatitis. Inview of the above findings, contrast-enhanced CTshould be performed only when the value of the infor-mation to be obtained exceeds disadvantages such asimpairment of renal function or an allergic reaction.The possible advantages of contrast-enhanced CT arethe visualization of pancreatic necrosis, the usefulnessof the findings in assessing the need for surgical man-agement and drainage, and occasional visualization offalse aneurysms, which may provide an opportunity toprevent their rupture.

T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines 65

Intensive care7

CQ7. What is important in the critical care of severeacute pancreatitis?

Appropriate infusion management, strict cardiovascu-lar and respiratory management, and the preventionand management of organ failure and infection are allimportant

Acute pancreatitis requires the basic management strat-egies that are described above. In critical cases, oxygenadministration, artificial respiration (ventilation), andmanagement of electrolytes and blood sugar should beperformed as required.

Continuous intravenous infusion of massive doses ofprotease inhibitors may decrease the incidence of com-plications in severe acute pancreatitis (Recommenda-tion B).

Because transjejunal enteral nutrition is superior tototal parenteral nutrition in the nutritional managementof pancreatitis, enteral nutrition should be administeredunless there are manifestations of ileus (Recommenda-tion A).

The prophylactic use of antimicrobial agents isunnecessary in mild and moderate cases, but theadministration of broad-spectrum antimicrobial agentswith good penetration into pancreatic tissue is requiredin severe cases, as this will help prevent infection (Rec-ommendation A).

Optional procedures for severe cases7

CQ8. What are some optional therapies for severeacute pancreatitis?

Blood purification therapy is used in the managementof severe acute pancreatitis, and continuous regionalpancreatic-arterial infusion of protease inhibitors/antimicrobial agents is used in the management ofnecrotizing pancreatitis (Recommendation C)

Selective digestive decontamination (SDD) can be usedin severe cases, but, because there has been only onerandomized controlled trial (RCT) of SDD (with a lim-ited number of patients), it remains unclear whethersystemic administration of antimicrobiotics or the com-bined use of the systemic administration of antimicrobio-tics and SDD is more efficacious (Recommendation C).

Blood purification, particularly continuous hemo-diafiltration (CHDF), may prevent severe acute pan-creatitis from progressing to multiple organ failure(Recommendation C). Continuous regional pancreatic-arterial infusion of protease inhibitors/antimicrobialagents may decrease the mortality rate and the inci-dence of infectious complications in patients with ne-crotizing pancreatitis (Recommendation C). However,

the efficacy of blood purification and pancreatic-arterialinfusion therapy will remain uncertain until confirmedby a high quality RCT. An RCT of continuous pancre-atic-arterial infusion is currently underway.

Assessing the complications of acute pancreatitis8

CQ9. How can the complications of acute pancreati-tis be assessed?

Patients should be examined for complications of acutepancreatitis, i.e., infected pancreatic necrosis and pan-creatic abscess, by abdominal ultrasonography (US)and abdominal CT scanning (Recommendation A)

Other recommendations are as follows:

(1) CT- or US-guided fine-needle aspiration biopsy(FNAB) should be performed when infected pan-creatic necrosis is suspected (RecommendationA).

(2) Infected pancreatic necrosis with signs of sepsis isan indication for surgical intervention (Recom-mendation B).

(3) Noninfected pancreatic necrosis is usually man-aged conservatively, in general, but those cases inwhich the patient’s condition does not improve (orvisceral disorders progress and infection cannot beruled out) are candidates for surgical intervention(Recommendation B).

(4) Early surgery is not recommended for necrotizingpancreatitis in the absence of specific indications(Recommendation B).

(5) Necrosectomy is recommended for the surgicalmanagement of infected pancreatic necrosis(Recommendation A).

(6) Simple drainage should be avoided as a method ofpost-necrosectomy management, and continuousclosed lavage or open drainage (plannednecrosectomy) should be selected instead (Rec-ommendation B).

(7) Pancreatic abscess should be managed bysurgical or percutaneous drainage (Recommenda-tion C).

(8) Pancreatic abscesses that do not respond clinicallyto percutaneous drainage should be immediatelytreated by surgical drainage (RecommendationB).

(9) Symptomatic cases, acute pancreatitis cases withcomplications, and pancreatic pseudocysts whosediameter is increasing should be treated by drain-age (Recommendation A).

(10) Surgical intervention should be selected for thosepancreatic pseudocysts that do not tend towardimprovement in response to percutaneous or en-doscopic drainage (Recommendation A).

66 T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines

Management policy for gallstone pancreatitis (Fig. 2)9

CQ10. Is the endoscopic approach beneficial in thetreatment of acute gallstone-induced pancreatitis?

Emergency endoscopic procedures should be given pri-ority in patients with acute gallstone-associated pan-creatitis with suspected bile duct obstruction and incases complicated by cholangitis (RecommendationA)

When a diagnosis of gallstone pancreatitis is made(based on imaging and blood biochemistry findings

performed immediately after medical examination),the patient should be examined for cholangitis andtransit disorders in the biliary tract, and severity shouldbe assessed. If the above complications are present,emergency endoscopic procedures (biliary calculusremoval and common bile duct drainage) are used,in combination with the management of severepancreatitis.

When these procedures cannot be used, percutane-ous biliary duct drainage or surgical decompression isperformed, as needed. Whether these drainage proce-dures are selected depends on the patient’s condition

Fig. 2. Management policy for acute biliary pancreatitis. ERC, endoscopic retrograde cholargiograhy; ES, endoscopic sphincter-otomy; ENBD, endoscopic nasobiliary drainage

T. Mayumi et al.: Management strategy for acute pancreatitis in JPN Guidelines 67

and the availability of specialist medical professionalsand the appropriate institution.

Emergency endoscopic procedures (endoscopic ret-rograde cholangiography [ERC] ± endoscopic sphinc-terotomy [ES], endoscopic papillary balloon dilatation[EPBD], endoscopic nasobiliary drainage [ENBD], andstenting) are designed to remove biliary calculi and todrain the biliary tract, and they can often relieve anyocclusion of the pancreatic duct.

It is important to transfer patients to an advancedspecialist medical institution if they are not able to un-dergo the needed procedures at the institution wherethey are being treated.

CQ11. Is one-stage cholecystectomy followed bycommon bile duct (CBD) clearance safer and moreeffective than endoscopic procedures?

Open choledochotomy or sphincterotomy (surgical re-moval of CBD stones) is recommended (Recommenda-tion D)

An RCT (Level 1b) [45] that compared patients whohad early surgery (within 72h after hospitalization) andthose who had delayed surgery found that there was nodifference in the incidence of complications (8.3% vs10.3%) or mortality (2.8% vs 6.9%) between the earlygroup and the delayed group. Another RCT (Level 1b)[46] revealed that early surgery (within 48h of hospitaladmission) was followed by a significantly higher inci-dence of complications (30.1% vs 5.1%) and mortality(15.1% vs 2.4%) than was delayed surgery (from 48honward after hospital admission). Because endoscopicprocedures such as ERC+ES can now be performedsafely, surgical removal or drainage of gallstones in theacute stage is not recommended if these endoscopicprocedures are indicated.

CQ12. When should laparoscopic cholecystectomybe undertaken in patients with gallstonepancreatitis?

Laparoscopic cholecystectomy during the same hospi-tal stay as the initial treatment is recommended forpatients with mild gallstone pancreatitis without com-plications (Recommendation B). Choledochotomyand/or choledocholithotomy are performed whendeemed necessary

In recent years laparoscopic operations have been in-creasingly used to treat many patients with gallstone-induced pancreatitis. According to the results ofprospective cohort studies (Levels 1b–2c) [16–21], thepercentage of patients in whom laparoscopic cholecys-tectomy was completed was 94.5% (range, 79% to100%), the incidence of complications was 5.5% (range,0% to 10%), and the mortality rate was 0.4% (range,0% to 2.5%), suggesting that the outcome oflaparoscopic operations is equal to or better than that oflaparotomy. Based on the above data, laparoscopiccholecystectomy may also be used in the managementof mild gallstone pancreatitis.

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