Received: 27 October 2018

DOI: 10.1111/jebm.12342

GUIDELINE

The consensus of integrative diagnosis and treatment of acute -2017

Junxiang Li Jing Chen Wenfu Tang

Digestive Disease Committee, Chinese Association of Integrative Medicine Abstract Correspondence (AP) is one of the most common acute abdominal diseases. The digestive Wenfu Tang,Digestive Disease Committee, disease committee, Chinese Association of Integrative Medicine, released Integrated traditional Chinese Association of Integrative Medicine. Chinese and Western medicine for diagnosis and treatment of acute pancreatitis in 2010.1 Since then, Department of Integrative Medicine, West China Hospital, Sichuan University, Chengdu 610041, further studies and great progress have been made by domestic and foreign counterparts from China. the perspective of both Chinese and Western medicine in AP, including the classification, fluid Email: [email protected] resuscitation, function maintenance, surgery intervention, enteral nutrition (EN), and The translators note: The consensus of Inte- syndrome differentiation and treatment. It is necessary to update the consensus on diagnosis and grative diagnosis and treatment of Acute treatment of integrated Chinese and Western medicine to meet clinical needs. Therefore, the Pancreatitis-2017 (Chinese version) has been published on Chinese Journal of Integrated Tra- 2012 Revision of the Atlanta Classification Standard (RAC) by the International AP Consensus,2 ditional and Western Medicine on , the 2013 the Management of Acute Pancreatitis by the American College of ,3, 4 2017(12): 901–909. the 2014 Guidelines for diagnosis and treatment of the acute pancreatitis guide (2014) by the Chinese medical association branch,5 the 2014 Guidelines on Integrative Medicine for Severe Acute Pancre- atitis by the Committee of the Chinese Society of Integrated Traditional Chinese and Western Medicine,6 and Traditional Chinese Medicine Consensus on the Diagnosis and Treatment for Acute Pancreatitis by the and committee of China Association of Traditional Chinese Medicine7, 8 were taken into account for the revision of the consensus published in 2010. The digestive specialists in Chinese and Western medicine had a discussion on traditional Chinese medicine (TCM) types, syndrome differentiation, the main points of integrative medicine, and so on. According to the Delphi method, Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis (the 2017 revision) has been passed after three rounds votes. (The voting options are as follows: (a) totally agree; (b) agree, but with some reservations; (c) agree, but with larger reservations; (d) disagree, but reserved; and (e) absolutely disagree. If more than two out of three choose (a), or over 85% choose (a) + (b), the consensus will be passed.) The final validation was carried out by the core expert group in Taizhou, Jiangsu on June 9, 2017. The full text is as follows.

KEYWORDS acute pancreatitis, consensus, diagnosis and treatment, integrative medicine

1 DEFINITION pancreatitis, pregnancy pancreatitis, and so on. According to the pres- ence and duration of organ failure and complication, it is divided into AP is defined as the acute inflammation of the , leading to three types: mild acute pancreatitis (MAP), moderate-severe pancre- systemic and local complications, including pancreatic edema, necro- atitis (MSAP), and severe acute pancreatitis (SAP).2 In addition, the sis, hemorrhage or , accompanied with peripancreatic fluid determinant-based classification for the severity (DBC), based on the collections, walled-off necrosis (WON), and organ dysfunction or fail- occurrence and duration of organ failure, pancreatic necrosis, and sec- ure outside the pancreas.1–8 On the basis of the etiology, AP can be ondary , is also considered and applied.9 Moreover, AP is classified as acute biliary pancreatitis (ABP), alcohol-related pancre- named “,” “Pi Xin Tong,” and “pancreatic fever” in tra- atitis, hyperlipidemic pancreatitis, wounded pancreatitis, drug-related ditional Chinese medicine (TCM).

c 2019 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd

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2 WEST MEDICINE DIAGNOSIS the Magnetic Resonance Cholangiopancreatography (MRCP) or endo- scopic retrograde cholangiopancreatography (ERCP) is recommended, 2.1 Clinical presentation but the routine use of diagnostic ERCP examination is unwarranted.

2.1.1 Symptoms 2.2.3 Special examination Patients with AP typically present with acute epigastric pain. The pain For patients who have undergone surgical management or percuta- is described as lasting, intense, and unbearable. The location of the neous catheter drainage (PCD), the routine uses of occult blood test, pain can affect the bilateral ribs, even radiating to the back of the drainage fluid enzymatic tests, chyluria tests, and biochemical tests waist. Patients with AP also commonly suffer from , vomiting, of abdominal drainage fluid are recommended. When patients have abdominal distension, , and less yellow urine, even anuria. undergone ERCP, it is time to perform drainage fluid (bile) culture. If Patients with AP may accompany with fever, cold or chills, and jaun- the intra-abdominal infection is suspected, it is critical to undergo bac- dice. Moreover, these symptoms, such as dyspnea, nervousness, pal- terial culture of specimens after the first percutaneous puncture or pitations, inability to lie down, restlessness, limbs coldness, oliguria or surgery as soon as possible. When is suspected in anuria, gibberish, lethargy, gastrointestinal bleeding, and so on, may be patients with autoimmune diseases, the detection of serum IgG4 levels manifested in severe cases. together with pancreatic histopathology is recommended.

2.1.2 Signs 2.3 Diagnosis The MAP only performs mild epigastric tenderness, whereas SAP accompanies with tenderness, rebound tenderness, and muscle ten- 2.3.1 Procedures of diagnosis sion in the upper or whole . Some of critically ill patients When the patient with abdominal pain is suspicious of AP,there are five present abdominal distension, blue-purple ecchymoses, abdominal steps to judge as follows: First, it is critical to confirm whether the exis- mass, intestinal type or peristaltic wave, abdominal wall varicose veins, tence of AP or not; second, based on the complications, organ function, and other performance. The blue-purple ecchymoses can be found and pancreatic morphology, disease episodes are dynamically evalu- at umbilical or bilateral abdominal subcutaneous, medial and lateral ated to classify the severity and evaluate the prognosis; third, poten- thighs, lumbar rib, or scrotum. tial etiologies are critical to being screened, such as biliary factors (bil- iary stones, infection, and obstruction), the tumors factors (pancreas, 2.2 Related inspections biliary, duodenal, and periampullary), and other factors, like hyper- lipidemia; fourth, it is critical to recognize the exists of comorbidi- 2.2.1 Laboratory routine examination ties or underlying diseases. Finally, AP is differentiated from chronic Laboratory examinations should be conducted for all patients after pancreatitis. admission. The routine laboratory parameters include pancreatic , routine blood test, and renal function, blood lipid, blood 2.3.2 Diagnostic criteria glucose, electrolytes, routine stool and urine test, arterial blood gas, AP is diagnosed by typical clinical symptoms, signs, laboratory tests, serum tumor markers, such as CEA, AFP, CA19-9, CA125, glycated and/or imaging examinations: (i) the typically abdominal pain consis- hemoglobin (HbA1c), fasting insulin, and C-peptide, serum inflamma- tent with AP, (ii) serum lipase activity and/or amylase greater than tory cytokines IL-6, IL-10, CRP, and procalcitonin (PCT). When the three times than the upper limit of normal, and/or (iii) characteristic infection is still suspected in patients with AP, the bacterial cultures of findings from abdominal imaging, contrast-enhanced computed tomo- blood, drainage, and sputum are recommended. graphic, and magnetic resonance imaging (MRI). When a doubt regard- ing the diagnosis of AP still exists by clinical presentation, routine labo- 2.2.2 Radiologic imaging examination ratory serum parameters, and abdominal imaging, the use of CT for the For all patients who are diagnosed with AP or suspected of AP, abdom- whole abdomen is recommended to confirm the diagnosis. inal imaging is useful to detect the pancreatic and peripancreatic changes and to screen the disease. When a doubt regard- 2.3.3 Severity evaluation ing the diagnosis of AP still exists by abdominal imaging, the use of The 2012 RAC severity grading standard is widely used in the clinical.2 computed tomography (CT) for the whole abdomen and lower chest First, two phases of AP are recognized: early (1-2 week of onset) and is recommended to confirm the diagnosis. The second CT scan within late (after 1-2 week of onset). MAP and SAP are differentiated based the first week is unwarranted. When the patients suffer from AP on whether there is organ failure within 24 hours after admission (Mar- for 1 week (especially within 48 hours), the contrast-enhanced CT shall score ˃ 2 points) or not. MSAP and SAP are differentiated based is only recommended to identify vascular lesions, such as abdomi- on whether organ failure can recover within 48 hours or not. In the nal vein thrombosis and strangulated intestinal obstruction, otherwise early stage, organ function damages/failures are used to classify the not. When patients accompany with elevated liver enzymes, with sus- disease severity. In the late stage, the pancreatic/pancreatic morpho- picious biliary stones or obstruction, with not confirmed information logical criterion is used as the basis for severity classification to guide by ultrasonography, or with no obvious abnormalities in ultrasound, treatment. Meanwhile, severity assessment indicators such as DBC,9

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Ranson, APACHE II, Balthazar CT classification, modified CT sever- usually differentiated as an interior syndrome, excess syndrome, and ity index, CRP, bedside severity assessment index, and harmless acute heat syndrome. The disease mainly locates in spleen, stomach, liver, pancreatitis score can also be applied. gallbladder, and intestine, sometimes involving heart, lung, kidney, and brain according to the theory of TCM. The basic pathogenesis of AP is 2.3.4 Diagnosis of SAP complicated with intra-abdominal ascending and descending disorder of spleen and stomach, liver fail- hypertension and abdominal compartment syndrome ing to maintain normal flow of Qi, and stomach disharmony because The elevation of intra-abdominal pressure (IAP) induced by SAP can of qi stagnation, dampness heat, blood stasis, and food stagnation eventually lead to intra-abdominal hypertension/abdominal compart- on middle-Jiao. The status of organ function and local complications ment syndrome (IAH/ACS), which causes organ damage or failure. IAP should be dynamically assessed during the whole course of the disease. is measured and monitored through the bladder. IAH, which is defined At the same time, it is worth to emphasize that early purgation treat- ≥ ment should not only use cold and bitter Chinese herbals. Promoting as continuous or repeated IAP pathologically elevation 16 cmH2O with no organ dysfunction, is divided into four grades. ACS is defined blood circulation and removing blood stasis are applied to the whole ≥ course, while Yin fluid should be preserved all the time. by the persistent IAP 26.6 cmH2O, and the existence of new organ dysfunction and failure.10

2.3.5 Identification of concurrent infections 3.1 In the early stage

The pancreatic or abdominal infection is commonly secondary to SAP. (1) Syndrome of liver depression and qi stagnation Biliary-related SAP should pay attention to the presence of biliary tract Main symptoms: (1) Right and middle upper abdominal pain, (2) infection, showing impotence or apathy, fever, cold or chills, jaundice, distension and pain of the bilateral hypochondrium relieved with sweating, increased heart rate, shallow or rapid breathing, increased afart. white blood cell count or below the normal lower limit with left nucleus Secondary symptoms: (1) Depression, irritability, and sighing, (2) shift, and PCT elevation. In the CT images, the increased pancreatic nausea and vomiting, (3) belching and hiccups, and (4) constipation. necrosis liquefaction area and peripancreatic effusion, or the accu- and pulse: Reddish tongue with thin white or thin yellow mulated gas in the area of pancreatic necrosis, and the aggravated coat and wiry and tight or wiry and rapid pulse, especially on left inflammatory response of surrounding tissues are the manifestations Guan. of infection. The positive fluid resuscitation cannot maintain the vital Diagnosis: Two main symptoms complicated with at least one sec- signs or organ functions, which also hint the infection. Bacteria can be ondary symptom. With atypical symptoms, tongue and pulsation, detected by B-ultrasound or CT-guided percutaneous fine needle aspi- as well as physic and laboratory examinations, should be consid- rate, as well as abdominal cavity puncture, blood, and the first surgi- ered. cal specimens. There are predisposing factors of secondary infection so (2) Syndrome of liver and gallbladder dampness and heat that broad-spectrum antibiotics should be considered. When patients Main symptoms: (1) Bilateral flank rib distension pain, (2) bitter have a high fever, conscious changes, blurred vision, or unexplained bil- taste and nausea. iary tract bleeding, deep fungal infections should be considered. Secondary symptoms: (1) Eyes and body with jaundice, (2) irregu- lar stool, (3) less and yellow urine, and (4) tired with poor appetite. 2.3.6 Diagnosis, dynamic assessment, and monitoring of Tongue and pulse: Red tongue with yellow greasy or thin yellow organ dysfunction coat and wiry and rapid or wiry, slippery, and rapid pulse, especially The SAP is prone to concurrent extrapancreatic organ function on left Guan. damage such as respiration, kidney, and cardiovascular function, and Diagnosis: Two main symptoms complicated with at least one sec- further deteriorates into two or more organs dysfunction or even fail- ondary symptom. With atypical symptoms, tongue and pulsation, ure simultaneously or sequentially. In clinical practice, organ function as well as physic and laboratory examinations, should be consid- damage or failure is evaluated by Mashall standard combined with ered. Sequential Organ Failure Assessment (SOFA), including ARDS Berlin (3) Syndrome of chest binding and interior excess 11 definition, the diagnosis, monitoring and processing of acute kidney Main symptoms: (1) Hard and full of pain in the chest, hypochon- injury (AKI), liver function damage, gastrointestinal dysfunction, blood drium, and upper abdomen, even with tenderness and (2) fullness system, cardiovascular system, and central nervous system injury and and discomfort in chest and hypochondrium failure. Secondary symptoms: (1) Alternating chill and fever, (2) vexation and vomiting, (3) difficulty and pain in micturition with short red 3 TCM SYNDROME DIFFERENTIATION urine, and (4) constipation. Tongue and pulse: Red tongue with yellow greasy or yellow thick The clinical manifestations of SAP are complex and diverse, and the and dry coat and slippery and rapid or deep tight or deep, rapid, early and the late stages are different. TCM syndromes are diverse, and powerful pulse. and treatment options are complex and variable. The simple drug Diagnosis: Two main symptoms complicated with at least one sec- could not treat all manifestations of AP. The nature of the disease is ondary symptom. With atypical symptoms, tongue and pulsation,

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as well as physic and laboratory examinations, should be consid- as well as physic and laboratory examinations, should be consid- ered. ered. (4) Syndrome of blood stasis (toxin) binding with hot (3) Syndrome of deficiency-cold in middle-Jiao Main symptoms: (1) Stabbing abdominal pain refused to press Main symptoms: (1) Abdominal contracture with pain and (2) without transferred and (2) bleeding, skin bruising, and freckle. predilection for warmth and for pressure by hand. Secondary symptoms: (1) Fever especially in night, (2) short red Secondary symptoms: (1) Vexation with palpitation, (2) short of urine, (3) dry and knotted stool, and (4) a palpable mass in the breath, (3) lusterless complexion, and (4) tired and poor appetite. abdomen. Tongueand pulse: Pale tongue or red tongue with little coat, thread Tongue and pulse: Red tongue or ecchymosis and wiry and rapid or left pulse, or slightly weak and uneven Cun pulse, and tight and hesitant pulse. wiry Chi pulse. Diagnosis: Two main symptoms complicated with at least one sec- Diagnosis: Two main symptoms complicated with at least one sec- ondary symptom. With atypical symptoms, tongue and pulsation, ondary symptom. With atypical symptoms, tongue and pulsation, as well as physic and laboratory examinations, should be consid- as well as physic and laboratory examinations, should be consid- ered. ered. (5) Syndrome of the internal blockade and external collapse (4) Syndrome of intermingled cold and heat with epigastric fullness Main symptoms: (1) Chill and fever, and polydipsia with profuse Main symptoms: (1) Epigastric fullness without pain and (2) vomit- sweating and (2) shortness of breath and tachypnea with restless- ing and . ness. Secondary symptoms: (1) Dry mouth with bitter, (2) poor appetite, Secondary symptoms: (1) Nausea and vomiting, (2) unconscious- (3) laziness, and (4) hiccupping repeatedly. ness, (3) abnormal feces and urine, and (4) skin spots. Tongue and pulse: Pale tongue with yellow and white or yellow, Tongue and pulse: Dry and dark tongue with gray-black and dry or thick, greasy, and dry coat and frivolous and foxy on right Guan old no coat and deep, thin, and weak or thin and rapid pulse. lightly taken, rather than atony deeply taken. Diagnosis: Two main symptoms complicated with at least one sec- Diagnosis: Two main symptoms complicated with at least one sec- ondary symptom. With atypical symptoms, tongue and pulsation, ondary symptom. With atypical symptoms, tongue and pulsation, as well as physic and laboratory examinations, should be consid- as well as physic and laboratory examinations, should be consid- ered. ered. (5) Syndrome of blood stasis Main symptoms: (1) Abdominal palpable masses and (2) abdominal 3.2 In the late stage effusion, pseudocyst, and WON in the image. (1) Syndrome of spleen deficiency Secondary symptoms: (1) Thirsty with no desire to drink, (2) local Main symptoms: (1) Abdominal distension and anorexia, (2) lazi- sting, (3) local tenderness, and (4) subcutaneous ecchymosis. ness, and (3) fatigue. Tongue and pulse: Pale dark or purple dark tongue with thin Secondary symptoms: (1) Nausea and vomiting, (2) vomiting clear white or yellow-white coat and deep and wiry or uneven water, (3) loose stools, and (4) glossy yellow and pale white com- pulse. plexion. Diagnosis: Two main symptoms complicated with at least one Tongue and pulse: Reddish tongue with the thin white coat, wiry secondary symptom. With atypical symptoms, tongue and pul- and tight pulse, weak and powerless pulse on right Guan, or deep sation, as well as physic and laboratory examinations should be week and powerless on right and left Cun without weak on Chi considered. pulse. Diagnosis: Two main symptoms complicated with at least one sec- ondary symptom. With atypical symptoms, tongue and pulsation, as well as physic and laboratory examinations, should be consid- 4 THERAPIES ered. 4.1 Principles of therapy (2) Syndrome of impairment of Qi and Yin Main symptoms: (1)Laziness and (2) hot flashes and night sweat- The aim for primary therapies with integrated Chinese and Western ing. medicine is to maintain vital organ function by restoring the stability Secondary symptoms: (1) Shortness of breath, spontaneous of the internal environment, improving gastrointestinal motility, and sweating, (2) mouth parched and tongue scorched, (3) dysphoria inhibiting inflammatory injury, to lower the mortality rate by reduc- and fever sensation in chest palms-soles, and (4) poor appetite. ing the occurrence of organ failure at the early stage. In the late stage, Tongueand pulse: Pale tongue or red tongue with little coat, thread the main goal is to restore organ function, to control infections and left pulse, or tread or tread and rapid pulse on left and right Cun. local complications. Meanwhile, efforts to shorten the hospital days Diagnosis: Two main symptoms complicated with at least one sec- and to lower the rate of surgery, transferring ICU, and mortality are ondary symptom. With atypical symptoms, tongue and pulsation, recommended.

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4.2 Routine management of Western medicine .15,16 When patients felt hungry and the symptoms of MAP/MSAP have improved, the oral feeding should be restarted.17 There is no need 4.2.1 Intensive monitoring to wait the moment when the abdominal pain has resolved and pan- Some parameters should be deserved to closely observe, such as vital creatic amylase level has restored into normal. Of course, oral feeding signs, abdominal symptoms, routine blood test, liver and renal function, with a low-fat solid diet appears as safe as a clear liquid diet.15 If nec- blood lipid, electrolytes, arterial blood gas, respiratory function, oxy- essary, nasogastric delivery is recommended.18 Nasojejunal delivery is gen index, acid-base balance, blood glucose, hematocrit (HCT), blood not superior to nasogastric delivery, thus the commencement of feed- lactic acid, hourly urine volume recording, bladder pressure, stool fre- ing should not be delayed for placing a nasojejunal feeding tube. Addi- quency, and radiologic imaging (including ultrasonography, CT or MRI). tionally, EN should be delayed in critical patients with uncontrolled The adjustment of the monitoring indicators and frequency is based on shock, uncontrolled hypoxemia and acidosis, uncontrolled upper GI the treatment goals. If necessary, the monitoring frequency with above bleeding, gastric aspirate >500 mL/6 h, bowel ischemia, bowel obstruc- parameters of every 4-6 hours is recommended. tion, abdominal compartment syndrome, and high-output fistula with- out distal feeding access.19 4.2.2 Fluid resuscitation In order to prevent from the occurrence of acute lung injury (ALI), AKI, 4.2.5 Management of IAH and ACS ACS, and heart failure, patients with SAP should perform a restric- The incidences of IAH and ACS of SAP are 60-80% and 12-30%, respec- tive fluid resuscitation strategy, in which the rates and total volume tively, so it makes sense to avoid the sustained IAH. The use of gastroin- are regulated by vital signs, urine output, lactate, and HCT to ensure testinal decompression, rectal anal decompression, gastrointestinal organ perfusion. The management of liquids should be strengthened. motility drugs, and traditional Chinese herbal medicine together with The parameters for fluid resuscitation should be clearly defined, such acupuncture treatment can take effect to decrease the IAP, as well as as the time points of starting and ending, the types of liquid (the pre- the paralytic ileus, which is treated with Neostigmine on some special ferred acetic acid balance liquid), the ratio of crystals to colloids, the acupoints. The long-time-accumulated positive fluid balance after fluid amount of liquid, and the infusion velocity with close monitoring of resuscitation should be avoided to prevent from IAH. If the hemody- plasma lactic acid. All infused fluids, which titrate to the endpoint, are namic is stable, diuretics or hemofiltration is recommended to correct included in the total calculation. At the same time, the fluid reactivity the positive fluid balance with overload fluid accumulation. As for obvi- assessment is carried out at the bedside. It is necessary to focus on ous peritoneal effusion and encapsulated effusion, PCD is encouraged. hemodynamic treatment which target is to relieve hemodynamic dis- When nonoperative measures fail to decrease IAH and to improve res- order slowly (The heart rate begins to slow down, and MAP tends to be piratory, renal, and cardiovascular functions, surgical decompression restored between 65–85 mmHg.) and which does not pursue a signif- therapy is recommended. Some clinical measures, for example, to take icant remission of hypovolemia in a short period of time.12 Moreover, effective analgesia and sedative and to maintain a proper body posi- the protocol of early goal-directed therapy for sepsis is not suitable for tion where the height of bed head is less than 30◦, can effectively help patients with AP. improve the abdominal wall compliance to prevent ACS.10

4.2.3 Prevention of infection 4.2.6 The use of somatostatin— inhibitor The infectious complications, both pancreatic (infected and necrosis) AP is induced by the activation of digestive enzymes in the pancreas. and extrapancreatic (bacteremia, pneumonia, urinary tract infections, However, the inhibition of enzyme secretion is controversial. It is not and so on), are the major causes of morbidity and mortality in patients clear whether pancreatic secretion continues to occur or not during with AP. Therefore, the timely management of pancreatic infection is the course of AP. Therefore, the routine use of somatostatin is not important. Antibiotics should be used in these situations: ABP,patients recommended, other than the growing pancreatic pseudocysts, pro- with SAP who deteriorate or fail to improve after 7-10 days of hos- gressive growth of WON, pancreatic leakage, and combined gastroin- pitalization, and AP accompanied with pancreatic or extrapancreatic testinal bleeding. According to the different condition, the incidence of infected necrosis. But the use of prophylactic antibiotics to prevent complications would be reduced by enzyme inhibitors such as Urinas- from infection for patients with MAP and sterile necrosis is not recom- tatin or Gabexate. mended, as well as the prevention of fungal infections. 4.2.7 The management of blood glucose 4.2.4 Nutrition When the SAP is complicated by hyperglycemia or patient has the It is believed that early enteral nutrition (EEN) has been demonstrated previous history of , blood glucose should be actively mon- as a protective effect on the integrity of enteric mucosa and the itored by Hb1C, insulin, and C-peptide. In the acute inflammatory decrease of infectious complications. Therefore, EEN should be recom- period, insulin therapy is initially preferred by following the first basic mended as soon as possible after admission,13,14 and parenteral nutri- then meal time management steps. Meanwhile, the dosage is adjusted tion should be considered only when EN has failed or the requested actively to make sure the blood sugar control in a safe range accord- nutritional goal has not been reached. EN cannot be administered due ing to protocols. Of course, the occurrence of hypoglycemia should be to increased pain, ascites or elevated fistula output, occlusion, and strictly avoided.

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4.2.8 The management of biliary diseases WON, which generally results in oppression or infection, requires intervention by drainage and combines with necessary necrotic tissue It is meaningful to differentially diagnose ABP. is one of removal in the late course.30 the most common etiology for AP. Because of the high incidence, abdominal ultrasound is widely used to assess cholelithiasis. The treatment of is divided into internal medicine, surgery, 4.2.10 Management of etiology to prevent recurrence 20,21 and endoscopic intervention. At the early stages, emergency The most common types of AP are biliary pancreatitis and alcoholic surgery is not advocated to relieve biliary obstruction. However, pancreatitis.27 ABP can be caused by gallstones, biliary tract infections, early endoscopic therapy has become the first line to manage ABP. acute or chronic , biliary tract tumors, biliary structural 22,23 ERCP/endoscopic sphincterotomy (EST) early is also encouraged. abnormalities, biliary cysts, ascariasis, and so on. The common treat- ABP with biliary obstruction should perform early ERCP/EST, nasal ment choice is ERCP or cholecystectomy. Primary and secondary drainage, and elective laparoscopic cholecystectomy (LC). hypertriglyceridemia can also induce AP, so the standard therapeutic When stones are highly suspected, MRCP or endo- measures are based on the use of lipid-lowering agents to reduce scopic ultrasonography should be performed. When AP combines the blood lipid levels below 5.65 mmol/L,31 and the blood lipid level concurrent acute cholangitis, ERCP should be implemented within should be reevaluated routinely after the discharge. The incidence of 24 24 hours of admission. When the common bile duct stones cause AP in diabetic patients is higher than that of nondiabetic patients, as obstruction with no remission after medical treatment, ERCP should well as the disease severity and length of hospital stay.32 Therefore, 25 be implemented within 72 hours of admission. In order to prevent strictly monitoring and controlling blood glucose are recommended. necrotizing ABP from infection, postoperative cholecystectomy should Alcohol-induced pancreatitis often manifests as a variable spectrum, be postponed until active inflammation has been relieved and fluid ranging from discrete episodes of AP to chronic irreversible silent accumulation has disappeared or stabilized. It is cautious to screen changes.33 Therefore, patients with AP should take a temperance for 26 the high-risk patients with AP after ERCP. By temporarily indwelling life. Smoking and drinking are common risk factors for AP. Cigarette pancreatic duct stent and/or giving nonsteroidal anti-inflammatory smoking is associated with a higher risk of developing chronic pancre- drug suppositories at rectal before the procedure, it should be utilized atitis (CP). Smoking induces chronic inflammation of pancreas along 27 to lower the risk of severe post-ERCP pancreatitis. But if ABP has with alcohol, high-fat diet, and other factors, especially the smoking no progressive biliary obstruction, ERCP is not required, and in case of history for more than 20 years. Even if quitting smoking, the influence nonbiliary SAP,single-episode AP is not recommended to do diagnostic would continue about 20 years. Early smoking cessation reduces the 23,24 ERCP. risk of pancreatic calcification.34 Therefore, patients with AP must quit smoking immediately and unconditionally. Smoking and drinking 4.2.9 Surgical indications and PCD are common risk factors for AP and CP, and alcohol and tobacco are related to calcification.35 Alcohol makes cigarette smoking a stronger Open surgical debridement has been long suspected, in that it risk factor and turns AP to be chronic.36 Other factors, such as obesity, increases morbidity and mortality. Therefore, surgical treatment pregnancy,37 and drugs, also have influences on the occurrence of AP. emphasizes the step-up ladder treatment concept, which is encour- aged to perform PCD or minimally invasive treatment initially and open surgery lately. During the course of step-up, the time of PCD 4.2.11 Sedative and analgesic implementation is determined according to the disease condition.28 In Sedative and analgesic can take effect to eliminate the pain, reduce the early stage, when severe ACS or persistent organ failure cannot anxiety and restlessness, help antagonize the inflammatory response, be relieved for more than 2 weeks, or patient has a large number of andimprovethepatient's abdominal wall compliance to prevent ACS ascites with obvious symptoms of infection, or ascites cannot be con- in patients with AP. Analgesics may be administered epidural, per- trolled by active nonsurgical treatment, or systemic symptoms or local cutaneous, or rectal, but there is a lack of the prioritized analgesics signs are not improved or aggravated after 2-3 days intensive treat- and dosing protocol to be recommended.38 So, we recommended ment in ICU, or the shock or vital organ dysfunction cannot be cor- that patients with SAP within 24 hours of hospital admission should rected, the regular surgery is recommended, otherwise not. In the late receive some degrees of analgesic treatment.39 Moreover, Chinese stage (4 weeks later), the surgical indicators contain the infected WON, medicine with electroacupuncture is also good for analgesia and peripancreatic or peritoneal infection, the growing pancreatic pseu- sedation.40 docyst, and WON with pressed symptoms to the adjacent organs.1 It is recommended to use a stepwise treatment protocol with mini- 4.3 Management of complications mally invasive and late laparotomy. When pseudocysts and WON fur- ther develop infections, abscesses, ruptures, and hemorrhages, it is Local complications of AP include acute peripancreatic fluid collection time to drainage, , or surgery29 For example, with progres- (APFC), acute necrotic collection (ANC), , and sive enlargement of pseudocysts or symptoms of digestive tract com- WON. APFC and ANC, which usually resolve with or without conser- pression, drainage is suggested to carry on.30 Asymptomatic WON vative treatment, would occur in the early stage. A pseudocyst will be does not mandate intervention, which may resolve spontaneously formed 4 weeks later without remission of APFC. If there is obstructive over time regardless of the size and location. However, symptomatic oppression, bleeding, or infection complications, intervention should

http://guide.medlive.cn/ 82 LI ET AL. be required. During the course waiting for the progression to WON (Rheum Palmatum L.), Shenggancao (Radix Glycyrrhizae), and (sterile or infected), if the organ failure continues or new organ so on. failure occurs, or the infection or sepsis merge, and the necrosis com- (2) Syndrome of liver and gallbladder dampness and heat bine with hemorrhage or obstruction, it is time for surgical interven- Treatment principle: Clearing away heat and dampness in liver and tion. The intervention, which carries on a step-up strategy including gallbladder PCD, transgastric puncture drainage, and necrotic tissue removal if Prescription: The modification of Yinchenhao Decoction (Treatise necessary, should be delayed as much as possible after 4 weeks of the on Febrile Diseases) combined with LongDanxiegan Decoction disease onset. MRCP is the best method to diagnose pancreatic leak- (Collection of Prescriptions with Notes) or Qingyi Decoction. age caused by the destruction of the pancreatic duct, and most of them Herbs include Yinchen (Artemisia capillaris Thunb.), Longdan- can be treated conservatively. Intervention treatment is only used for cao (Gentiana scabra Bunge), Dahuang (Rheum palmatum L.) the failure of pancreatic leakage, pancreatic ascites, pancreatic pleural (decoct later), Zhizi (Gardenia jasminoides Ellis), Chaihu (Bupleu- effusion, high flow , and so on after the nonoperative rum chinensis DC.), Zhishi (Immature Bitter Orange), Muxiang treatment. During the AP, vascular complications such as splenic vein (Radix Aucklandiae)(decoct later), Huanglian (Coptis chinensis thrombosis, pancreatic , pseudoaneurysm, arte- Franch.), Yanhusuo (Corydalis yanhusuo W. T. Wang), Huangqin rial hemorrhage should be routinely examined, diagnosed, and corre- (Scutellaria baicalensis Georgi), Cheqianzi (Semen Plantaginis), spondingly treated. At the same time, when complications of jaundice Tongcao (Medulla Tetrapanacis ), Shengdihuang(Rehmannia and export disorders occur during the course of AP, they should be glutinosa Li-bosch.), and Danggui (Angelica sinensis). When com- actively managed. bined with jaundice, treatment can be differentiated from Yin- jaundice and Yang-jaundice according to the syndrome differen- 4.4 Treatment of systemic complications tiation. (3) Syndrome of chest binding and interior excess AP is often accompanied by sepsis, so it ought to take positive com- Treatment principle: Removing stasis by purgation, regulating Qi, prehensive treatment, like anti-infective, fluid resuscitation, maintain- and activating blood ing organ function, and to monitor blood lactic acid and lactic acid Prescription: The modification of Qingyi Decoction and Daxianx- clearance rate after the sepsis occurred.41 When combining the appro- iong Decotion (Treatise on Febrile Diseases). Herbs include Chaihu priate fluid resuscitation and gastrointestinal decompression, neces- (Bupleurum chinensis DC.), Huangqin (Scutellaria baicalensis sary thoracic puncture drainage, and mechanical respiration support Georgi), Zhishi (Immature Bitter Orange), Houpo (Magnolia henryi with ALI/ARDS or AKI,42 timely and necessary CRRT treatment would Dunn.), Danpi (Cortex Moutan), Yuanhu (Corydalis yanhusuo W. T. be the optional choices,43 but the bedside dialysis or hemofiltration Wang), Chuanlian (Melia toosendan Sieb. et Zucc.), Shengdahuang treatment cannot easily be used.44 Combined with acute liver func- (Rheum palmatum L.), Mangxiao (Natrii Sulfas) (granules), Gansui tion damage, treatment for normalizing gallbladder to cure jaundice or powder (Euphorbia kansui T. N. Liou ex S. B. Ho), and so on. hepatoprotective treatment would be adopted according to the condi- tion. In combination with acute heart injury, brain injury, and coagula- (4) Syndrome of blood stasis(poison)binds tion dysfunction,45 it should actively treat the primary disease of SAP, Treatment principle: Clearing heat and purging fire, removing reduce inflammatory reactions, and deal with the symptoms. In severe blood stasis, and communicating with the Fu organs. cases, it is necessary to transfer to the ICU to strengthen intensive care Prescription: The modification of Xiexin Decoction (Treatise on and treatment. Febrile Diseases) or Dahuangmudan Decoction (Synopsis of the Golden Chamber) combined with Gexiazhuyu Decoction (Correcting Mistakes by Medical Forests). Herbs include Dahuang (Rheum 4.5 TCM treatment palmatum L.), Huanglian(Coptis chinensis Franch.), Huangqin 4.5.1 TCM syndrome differentiation and treatment (Scutellaria baicalensis Georgi), Danggui(Angelica sinensis), Chuanxiong (Ligusticum chuanxiong Hort.), Taoren (Peach In the early stage Seed), Honghua (Carthamus tinctorius Linn.), Chishao (Radix Paeoniae Rubra ), Yanhusuo (Corydalis yanhusuo W. T. Wang), Shengdihuang(Rehmannia glutinosa Li-bosch.), Danshen (Radix (1) Syndrome of liver depression and Qi stagnation Salviae Miltiorrhizae), Houpo (Magnolia henryi Dunn.), Stir fried Treatment principle: dispersing stagnated liver Qi Wulinzhi (Faeces Trogopterori), Mudanpi (Cortex Moutan), and Prescription: The modification of Chaihu Shugan Powder (Jing Mangxiao (Natrii Sulfas)(granules). For those with severe toxicity Yue Book) and Qing Yi Decoction; herbs includes Cuchaihu (stir- and heat, Huanglianjiedu Decoction, Xijiaodihuang Decoction, baked Bupleurum Chinensis DC. with vinegar), Zhike (Fructus Qingyijiedu Decoction, and Angong Niuhuang Pill were added Aurantii), Zexie (Alisma Plantago-Aquatica Linn.), Chuanxiong as appropriate. In the early course of AP, the inflammation or (Ligusticum chuanxiong Hort.), Chenpi (Pericarpium Citri Rehman- secondary infection can lead to fever, and the residual infection niae), Fabanxia (Rhizoma Pinelliae Praeparata), Houpo (Mag- or fluid effusion can also cause fever due to deficient vital Qi and nolia Henryi Dunn.), Yujin (Radix Curcumae), Danshen (Radix lingering of the pathogen in the late stage. It is time to take care Salviae Miltiorrhizae), Baishao (Paeonia Lactiflora Pall.), Dahuang

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of Yang Qi and not to be dedicated to clearing away the heat and (4) Syndrome of intermingled cold and heat with epigastric fullness detoxification. Treatment principle: Balanced regulation between cold and heat, (5) Syndrome of the internal blockade and external collapse disintegrating masses, and eliminating stagnation. Treatment principle: Purging the bowels and expelling stasis and Prescription: The modification of Banxia Xiexin Decoction (Trea- returning yang to relieve the adverse effects. tise on Febrile Diseases). Herbs include Banxia (Rhizoma Pinel- Prescription: The modification of Xiaochengqi Decoction (Trea- liae Praeparata), Huanglian (Coptis chinensis Franch.), Huangqin tise on Febrile Diseases) and Sini Decoction (Treatise on Febrile Dis- (Scutellaria baicalensis Georgi), Ganjiang (Rhizoma Zingiberis), eases). Herbs include Shengdahuang (Rheum palmatum L.), Houpo Gancao (Radix Glycyrrhizae), Dazao (Fructus Jujubae), Renshen (Magnolia henryi Dunn.), Zhishi (Immature Bitter Orange), Shufuzi (Panax ginseng C. A. Meyer), Danshen (radix salviae miltiorrhizae), (Radix Aconiti Lateralis Preparata), Ganjiang (Rhizoma Zingiberis), and so on. Gancao (Radix Glycyrrhizae), Gegen (Radix Puerariae), Chishao (5) Syndrome of blood stasis (Radix Paeoniae Rubra ), Honghua (Carthamus tinctorius Linn.), Treatment principle: Activating blood circulation to dissipate and Shengshaishen (dry Radix Ginseng)(another stew). Conform- blood stasis, promoting Qi, and relieving pain. ing to the change of mind and another pancreatic encephalopathy, Prescription: The modification of Xuefu Zhuyu Decoction (Correc- we should carry out corresponding treatment based on syndrome tions on the Errors of Medical Works). Herbs include Taoren (Peach differentiation. Seed), Honghua (Carthamus tinctorius Linn.), Danggui (Angelica sinensis), Shengdihuang (Rehmannia glutinosa Li-bosch.), Niuxi Inthelatestage (Achyranthes bidentata Blume), Chuanxiong (Ligusticum chuanx- iong Hort.), Jiegeng (Platycodon grandifloras A. DC.), Chishao (Paeonia lactiflora Pall.), Zhike (Fructus Aurantii), Gancao (Radix (1) Syndrome of spleen deficiency Glycyrrhizae), and Chaihu (Bupleurum chinensis DC.). If blood sta- Treatment principle: Replenishing Qi and invigorating the spleen. sis is blocked in the left abdomen, it can be treated with Guizhi Ful- Prescription: The modification of Buzhong Yiqi Decoction (Internal ing Pill (Synopsis of Golden Chamber). If it is located in the lower and External Injury and Confusion). Herbs include Huangqi (Astra- abdomen, Taohe Chengqi Decoction could be used (Treatise on galus membranaceous Bge.), Zhigancao (Radix Glycyrrhizae), Febrile Diseases), while Bentun Decoction is suitable for the sta- Renshen (Panax ginseng C. A. Meyer), Danggui (Angelica sis in the right abdomen (Synopsis of Golden Chamber) and Danggui Sinensis), Jupi (Citrus tangerina Hort.et Tanaka C.erythrosa Shaoyao powder for the stasis in periumbilicus (Synopsis of Golden Tanaka), Shengma (Cimicifuga foetida Linn.), Chaihu (Bupleurum Chamber). Chinensis DC.), Baizhu (Atractylodes macrocephala Koidz.), Danshen (Radix Salviae Miltiorrhizae), and so on. Syndrome of Yang deficiency in middle-Jiao can be treated by the Lizhong 4.5.2 Treatment of Chinese patent medicine decoction. Those syndromes with spleen deficiency and excessive (1) Pill of Cyperus and Amomum with six noble ingredients dampness can be managed with Shenling Baizhu San (Prescriptions Muxiang (Radix Aucklandiae), Sharen (Fructus Amomi), Chenpi of the Bureau of Taiping People). (Pericarpium Citri Reticulatae), Zhibanxia (Processed Rhizoma (2) Syndrome of impairment of Qi and Yin Pinelliae), Dangshen (Radix Changii), Baizhu (Radix Atractylodis Treatment principle: Replenishing Qi and nourishing Yin Macrocephalae), Fuling (Poria cocos wolf.), and Zhigancao (Pre- Prescription: The modification of Sheng Mai San (Internal and pared Radix Glycyrrhizae). It is able to replenish Qi and invigorate External Injury and Confusion)andYiWeiTang(Detailed Analy- spleen, regulate Qi and harmonize stomach, and serves to treat sisofEpidemicWarmDiseases). Herbs include Renshen (Panax spleen deficiency and Qi stagnation. Direction: 6-9 g each time, ginseng C. A. Meyer), Maidong (Ophiopogon japonicus Ker- two times a day. Gawl.), Wuweizi (Schisandra chinensis Baill.), Shengdi (Rehmannia (2) Lizhong pill glutinosa Li-bosch.), Xuanshen (Scrophularia ningpoensis Hemsl.), Renshen (Panax ginseng C. A. Meyer), Baizhu (Atractylodes macro- Yuzhu (Polygonatum odoratum Druce), Beishashen (Adenophora cephala Koidz.), and Ganjiang (Rhizoma Zingiberis), Gancao (Radix stricta Miq.), and so on. Glycyrrhizae). It is able to warm middle-jiao and dispel cold, invig- (3) Syndrome of deficiency-cold in middle-Jiao and liver-spleen orate the spleen, and harmonize stomach. It serves to treat the fol- disharmony lowing syndromes: spleen and stomach deficiency, vomiting and Treatment principle: Warming middle-Jiao and tonifying defi- diarrhea, a chest full of abdominal pain, and . Direction: ciency to relieve spasm and pain. eight pills at a time, three times a day. Prescription: The modification of Xiaojianzhong Decoction (Trea- (3) Guizhi Fuling pill tise on Febrile Diseases). Herbs include Yitang (Glucidtemns), Guizhi Guizhi (Cinnamomum cassia Presl), Fuling (Poria cocos wolf.), (Cinnamomum cassia Presl), Shaoyao (Paeonia lactiflora Pall.), Mudanpi (Cortex Moutan), Chishao (Radix Paeoniae Rubra), and Shengjiang (Zingiber officinale Rosc.), Dazao (Fructus Jujubae), Taoren (Peach Seed). It is able to promote blood circulation, Zhigancao (Radix Glycyrrhizae), Danshen (radix salviae miltior- remove phlegm and eliminate diseases. It serves to treat the blood rhizae), and so on. stasis syndrome, in which the accumulation of blood stasis and

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effusion is mainly blocked on the left side. Direction: one pill at a taken and the needle is kept for 30 minutes, one-two times a day, time, one or two times a day. 1-3 weeks for a course of treatment.46 (4) Xuefu Zhuyu Oral Liquid (tablet) (4) Acupoint injection Taoren(Peach Seed), Honghua (Carthamus tinctorius Linn.), Dang- When patients’ heart rate is more than 100 beats/min without gui (Radix Angelicae Sinensis), Chuanxiong (Rhizoma Chuanxiong), the history of heart disease and prostatic hypertrophy, bilateral Dihuang (Rehmannia glutinosa), Chishao (Radix Paeoniae Rubra), Zusanli (st 36) can be selected to inject neostigmine 0.5 mL a time, Niuxi (Radix Achyranthis Bidentatae), Chaihu (Radix Bupleuri), otherwise metoclopramide 10 mg a time, two-three times a day, 3- Zhike (Fructus Aurantii), Jiegeng (Radix Platycodi), and Gaocao 7 days during the course of treatment. Meanwhile, the frequency (Radix Glycyrrhizae). It is used to promote blood circulation and and the end time are dependent on the gastrointestinal motility remove stasis and it also promotes Qi circulation to relieve pain. and stool conditions. It serves to treat blood stasis internal resistance syndrome. Direc- tion: two or six pieces at a time, two times a day. 4.7 Psychotherapy (5) Kangfuxin solution Dry worm extract from the American cockroach. It is able to The treatment environment should be quiet and comfortable. Doctors resume blood stream, nourish Yin, and promote granulation. should communicate fully with the patients and make necessary expla- Whether external use or oral feeding, it serves to treat blood stasis nations and help them eliminate fear and build confidence to overcome syndrome, postoperative wound healing, ulcer bleeding, and so on. the disease on the basis of necessary effective analgesia and sedation. Direction: 10 mL at a time, three times a day. (6) Compound Glutamine Entersoluble capsule L-glutamine, Baizhu (Rhizoma Atractylodis Macrocephalae), Fold- 4.8 Essentials of integrative management ing (Poria cocos wolf.), and Gancao (Radix Glycyrrhizae). It is 4.8.1 Prevention and treatment of acute gastrointestinal able to invigorate the spleen and replenish Qi and serves to pro- injury and ACS by Chinese medicine to remove stasis through mote the recovery of intestinal function and improve appetite for purgation intestinal dysfunction after AP. Direction: two-three capsules at a Acute gastrointestinal injury (AGI), caused by SAP, is manifested as time, three times a day. gastrointestinal dysfunction, gastrointestinal mucosal injury, intesti- nal edema, hemorrhage, paralytic ileus, and fat infiltration around the 4.6 Characteristic Chinese medicine treatment superior mesenteric artery. However, the AGI is the source and trig- ger that the injuries of external organs such as heart, lung, and brain The unique treatment of TCM includes the external application of Chi- are induced by SAP.47 In recent years, it has been found that the dam- nese medicine, acupuncture therapy, abdominal massage therapy, acu- age of the barrier in SAP plays a key role in point sticking therapy, acupoint injection therapy, pressing, moxibus- their pathophysiology process, which could induce IAH, ACS, intesti- tion, acupoint embedding, and so on. nal bacterial translocation and intestinal endotoxemia, or eventually SIRS/MODS. Therefore, effectively controlling AGI is one of the key points to improve the prognosis of AP.On the basis of the treatment of (1) External application of TCM ointment inhibition of and bleeding, promotability of gastrointestinal According to the location of the ANC, WON, or pancreatic pseudo- motility, and alleviating peripancreatic inflammatory response, tradi- cyst in the abdomen or the retroperitoneum, and the classification tional herbal medicine and acupuncture are recommended to promote of ACS, the Liuhe Dan or self-made Huoxue Zhitong paste could be Qi movement and activate blood circulation to remove stasis for AGI. applied to the corresponding body parts. Direction: 6-8 hours each The role of AGI as an engine for MODS in critically ill will be blocked. time, once a day. The digestive function also can be restored as soon as possible, while (2) External application of Mangxiao (mirabilite) the traditional concept of pancreas rest is abandoned, and the intesti- Refined fine-grained mirabilite is selected, which uses cotton to nal arouse is intensified to guide early oral refeeding. package. According to the extent and location of peritoneal effu- sion and edema of the pancreas and surrounding tissues, it is exter- nally applied to the corresponding parts. Direction: 2-8 hours each 4.8.2 Benefiting Qi and nourishing Yin to prevent early time, one-three times a day. hypovolemia and shock and improving organ perfusion (3) Acupuncture therapy A large loss of body fluid to the third space is caused by the inflamma- It is important to select Zusanli (st 36), sanyinjiao (sp 6), Yan- tory exudation of AP, resulting in shock because of insufficient circu- glingquan (Gb 34), Neiguan (P 6), Zhigou (TE 6), and Hegu (Li4) lating blood volume or infection of the biliary tract and abdominal cav- to acupuncture, with a 1.5-inch needle. According to the results ity. Restrictive fluid resuscitation is recommended. At the same time, of syndrome differentiation, acupoints are modified to carry on the treatment with TCM of benefiting Qi and nourishing Yin is used different reinforcing and reducing manipulating techniques, com- to recover early hypovolemia. The circulation will also be improved to bined with electroacupuncture. Each time six to 12 acupoints are treat shock and protect organ function.

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4.8.3 Early prevention and treatment of organ function and necessary interventions before discharge are recommended, damage/failure based on lung and being including quitting smoking and drinking, changing dietary habits and interior-exteriorly related structure, monitoring and controlling blood lipid and blood sugar, con- trolling weight, preventing biliary stones, and insisting on long-term AGI, induced by AP,is the engine of MODS, which results in the damage outpatient follow-up or APP automatic follow-up review. of respiratory system, kidney, heart, and brain. All organ injuries can be reinforced each other, and a vicious circle will be formed to affect the progress of the disease. The overall mortality rate is above 20%. How- ever, the mortality rate can be as high as 35-50% in the first week, due 5 EFFICACY ASSESSMENT CRITERIA to the injury or failure of single or multiple organs. Hence, while the inflammatory response is actively regulated, and the organ function is The evaluation criteria of the efficacy of AP treatment include eval- effectively supported, Chinese herbal medicine is served to treat AGI uation criterion of clinical symptoms and signs, efficacy evaluation for relieving ACS. Meanwhile, new organ damage or the improvement of serum pancreatic enzymes, efficacy evaluation of imaging, effi- of original organ damage can be prevented. The occurrence of MODS cacy evaluation of syndromes of TCM, evaluation criteria of pancre- and the early mortality rate can be reduced ultimately, and the ventila- atic endocrine and exocrine functions, and evaluation of life qual- tor can be removed as soon as possible. ity. Up to now, the main endpoints of efficacy evaluation criteria have been adopted in most international clinical trials, including case 4.8.4 Prevention of infection by clearing heat and fatality rate, complication rate (fluid collection, WON, IPN, and hem- detoxifying orrhage), surgical rate, and length of stay. However, there is no uniform and widely used clinical efficacy evaluation standard or pro- The infection is the main cause of high mortality in the late stage of tocol for TCM in domestic clinical research, which makes it impossi- SAP. In the early stage, it is crucial to exert a correct fluid resuscitation ble to perform an effective and reasonable comparison between clin- protocol, improve gastrointestinal motility, and prevent bacterial ical trials and fails to demonstrate the efficacy of TCM treatment for translocation. In the later stage, the treatments of pancreatic necrosis, AP. Based on Consensus on the Diagnosis and Treatment for Acute Pan- fluid collection, pseudocyst, or WON are paid more attention. If creatitis by the Spleen and Stomach committee of China Association necessary, PCD or surgical drainage can be properly carried on, and of Traditional Chinese Medicine, combined with international research activating blood and promoting water in TCM are also recommended. experience, unified efficacy evaluation criterion is used for clinical Minimizing invasive interventions, removing tubes of invasive inter- trial. The clinical symptoms and signs, and imaging features are rec- ventions, and transferring patients out of the ICU as soon as possible ommended to be the main evaluation criteria. Moreover, these evalua- are used to reduce the incidence rate of infection.48 Strengthen- tions, combined with serology, Chinese medicine syndromes, individual ing infection surveillance includes timely collecting specimens of TCM symptoms, and life quality, are secondary. Details are provided as suspected infected patients for bacterial culture to actively obtain follows. the drug-sensitive results, which help to guide antibiotic selection. Meanwhile, the treatments of TCM, like clearing heat and detoxifying, activating blood and removing stasis, are used to synergistically reduce 5.1 Assessment criteria: Clinical symptoms and the incidence of infection and the late mortality rate. signs

Patients with AP have abdominal pain and abdominal distension as 4.8.5 Activating blood and removing stasis to prevent and the main symptoms, with common signs such as abdominal tender- treat the late stage complications and reduce the rate of ness, rebound tenderness, and muscle tension. The grading is deter- surgery mined by changes in symptoms and signs at the time of admission and In the late stage of SAP, ileus is caused by pseudocysts, WON, before discharge. Clinical recovery: Main symptoms and signs have infected pancreatic necrosis (IPN), hemorrhage, pancreatic portal disappeared. Markedly effective: Significant improvement in the main hypertension, gastric outlet disorders, inflammatory adhesive intesti- symptoms and signs, without affecting the patient's appetite and rest. 49 ' nal obstruction, or intestinal obstruction. Not only the patient s life Effective: Significant improvement in major symptoms and signs, with quality after discharge is affected, but the severe lesions could also minor influence on patients' appetite and rest. Ineffective: No signifi- occur, which result in an increasing surgical rate and mortality. There- cant improvement in main symptoms and signs, or even aggravation. fore, according to different complications and their causes, targeted The degree evaluation of abdominal pain and abdominal distension: syndrome differentiation and treatment is recommended to carry out As to comprehensive assessment of efficacy, abdominal pain is the 50 to reduce the operation rate and improve the prognosis. main symptom and abdominal distension is the secondary syndrome. The visual analogue scale (VAS) method is used to record the degree 4.8.6 Strengthening the etiologic management of AP to of abdominal pain and abdominal distension, which depend on the sub- preventively treat disease jective symptom grading of patients. On the basis of 100 mm vertical The recurrence of AP, the family, and socioeconomic burden can scale, the 0 mm is defined as the minimum with no pain or abdominal be effectively reduced by strengthening the etiologic management. distension, and the 100 mm is defined as the maximum and unbearable Combined with the specific etiology of the patient, health education pain or abdominal distension. Pati ents are requested to make a mark

http://guide.medlive.cn/ 86 LI ET AL. on the scale, which can reflect the levels of their pain and abdominal original symptoms have not improved or even worsened. Symptom distension. The VAS method is used to score the degree of pain and grading records: Level 0—no symptoms, 0 points; Level 1—minor symp- abdominal distention, separately on the 0th, 2nd, 5th, 7th, and 14th toms without influence on daily life, 1 point; Level 2—moderate symp- days. The efficacy is judged by using the nimodipine method and the toms partially affecting daily life, 2 points; Level 3—severe symptoms following criteria. affecting daily life or even normal work, 3 points.

5.2 Assessment criteria: Laboratory test results ADDITIONAL INFORMATION Clinical recovery: Pancreatic enzymology (amylase and lipase), liver and renal function, blood lipid, blood glucose, and routine blood test Experts participating in this consensus opinion are as follows (ranked have returned to normal. Markedly effective: Pancreatic enzymology by last name strokes): Wang Chang-Hong, Gan Chun, Feng Wu-Jin, Nv has returned to normal, but liver and renal function, blood lipid, blood Bin, Wei Bei-Hai, Liu Cheng-Hai, Jiang Xue-Liang, Lao Shao-Xian, Li glucose, and routine blood test have not fully returned to normal. Effec- Tian-Wang, Li Jun-Xiang, Li Yan, Li Gang, Li Yong, Li Dao-Ben, Yang Guo- tive: Pancreatic enzymology has significantly reduced, but liver and Hong, Yang Chun-Bo, Yang Shen-Lan, Xiao Bing, Wu Yun-Lin, He Xiao- renal function, blood lipid, blood glucose, and routine blood test are not Hui, Shen Hong, Shen Wei, Zhang Wan-Dai, Zhang Rong-Hua, Chen all normal. Ineffective: Pancreatic enzymology, liver and renal function, Zhi-Shui, Chen Hai-Long, Chen Jing, Lin Shou-Ning, Shang Dong, Zhou blood lipid, blood glucose, and routine blood test have not returned to Zheng-Hua, Zhao Wen-Xia, Zhao Hong-Chuan, Hu Ling, Ke Xiao, Cha normal. An-Sheng, Yao Xi-Xian, Yao Shu-Kun, Xu Ke-Cheng, Ling Jiang-Hong, Tang Xu-Dong, Tang Zhi-Peng, Tang Yan-Ping, Liang Jian, Xie Sheng, 5.3 Assessment criteria: Pancreatic imaging Xie Jing-Ri, Dou Yong-Qi, and Wei Pin-Kang. Project manager: Li Jun- evaluation index Xiang, Chen Jing. Consensus’ writers: Tang Wen-Fu.

The pancreatic and surrounding lesions are recommended to be used as evaluation indicators. Clinical recovery: The pancreatic morphol- CONFLICT OF INTEREST ogy and parenchyma have returned to normal without effusion, edema, The author has no conflicts of interest to report. pseudocyst, or enveloping necrosis. Markedly effective: The pancre- atic morphology and parenchyma have not returned to normal, but abdominal pain and abdominal distension cannot exist with no influ- REFERENCES ' ence on the patient s appetite and rest. Effective: The pancreatic mor- 1. Chinese Committee of Integrative Medicine for Digestive System Dis- phology and parenchyma have not returned to normal, but abdominal eases. Diagnosis and treatment of acute pancreatitis with integrated pain and abdominal distension can exist affecting the patient's appetite traditional Chinese and Western medicine. Chin J Integr Tradit Western Med Digestion. 2011;19:209–209. and rest. Ineffective: The pancreatic morphology and parenchyma have not returned to normal, but abdominal pain and abdominal distension 2. Banks P A, Bollen T L, Dervenis C, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions can exist, even the patient cannot normally feed and rest. by international consensus. Gut. 2013;62:102–111. 3. Tenner S, Baillie J, Dewitt J, et al. American College of Gastroenterol- 5.4 Assessment criteria: TCM syndrome ogy guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108:1400–1415. Efficacy index = (points before treatment – points after treatment) / 4. Deviere J. IAP/APA evidence-based guidelines for the management of points before treatment × 100%. All symptoms are divided into four acute pancreatitis. Pancreatology. 2013;13:e1–e15. levels: No, mild, moderate, and severe. In the main card, 0, 2, 4, and 5. Pancreatic Surgery Group of Surgery Branch of Chinese Medical Asso- 6 points are recorded, respectively, and in the secondary card, 0, 1, ciation. Guidelines for the diagnosis and treatment of acute pancreati- tis (2014 edition). Chin J Digestive Surg. 2015;35:4–7. 2, and 3 points are recorded, respectively. Clinical recovery: The main 6. General Surgery Committee, China Society of Integrated Traditional symptoms and signs have disappeared, and the efficacy index is ≥95%. Chinese and Western Medicine. Guidelines for integrated traditional Markedly effective: Significant improvement in major symptoms and Chinese and Western medicine diagnosis and treatment of severe signs, 70% ≤ efficacy index <95%. Effective: The main symptoms and acute pancreatitis (2014, Tianjin). J Clin Hepatol. 2014:20:460–464. signs have improved significantly, 30% ≤ efficacy index <70%. Ineffec- 7. The Spleen and Stomach Disease Branch of China Association of Chi- tive: The main symptoms and signs have not improved significantly or nese Medicine. Consensus on acute pancreatitis management of Chi- even worsened, and the efficacy index is <30%. nese medicine. China J Tradit Chin Med Pharmacy. 2013;28:826–1831. 8. Pancreatology Committee of Chinese Medical Doctor Association. Chinese consensus on acute pancreatitis by multiple discipline team 5.5 Assessment criteria: Individual TCM symptom (Draft). Chin J Pract Intern Med. 2015;35:1004–1010. 9. Dellinger EP, Forsmark CE, Layer P, et al. Pancreatitis Across Nations Markedly effective: The original symptoms have disappeared. Effec- Clinical Research and Education Alliance (PANCREA) Determinant- tive: The original symptoms have improved by two levels. Progress: based classification of acute pancreatitis severity: an international The original symptoms have improved by one level. Ineffective: The multidisciplinary consultation. Ann Surg. 2012;256:875–880.

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