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The Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis-2017

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The Consensus of Integrative Diagnosis and Treatment of Acute Pancreatitis-2017 Received: 27 October 2018 DOI: 10.1111/jebm.12342 GUIDELINE The consensus of integrative diagnosis and treatment of acute pancreatitis-2017 Junxiang Li Jing Chen Wenfu Tang Digestive Disease Committee, Chinese Association of Integrative Medicine Abstract Correspondence Acute pancreatitis (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, organ 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 Digestion, the 2013 the Management of Acute Pancreatitis by the American College of Gastroenterology,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 General Surgery 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 Spleen and Stomach 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 pancreas, 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 infection, 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 infections, is also considered and applied.9 Moreover, AP is classified as acute biliary pancreatitis (ABP), alcohol-related pancre- named “abdominal pain,” “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 76 wileyonlinelibrary.com/journal/jebm JEvidBasedMed.2019;12:76–88. http://guide.medlive.cn/ LI ET AL. 77 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 nausea, vomiting, of abdominal drainage fluid are recommended. When patients have abdominal distension, constipation, 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 chronic pancreatitis 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 abdomen. 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 enzymes, routine blood test, liver 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 biliary tract 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
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