[Skip to Content]
[Skip to Content Landing]

Acute PancreatitisA Review

Educational Objective
To review the clinical management of patients with acute pancreatitis.
1 Credit CME

Importance  In the United States, acute pancreatitis is one of the leading causes of hospital admission from gastrointestinal diseases, with approximately 300 000 emergency department visits each year. Outcomes from acute pancreatitis are influenced by risk stratification, fluid and nutritional management, and follow-up care and risk-reduction strategies, which are the subject of this review.

Observations  MEDLINE was searched via PubMed as was the Cochrane databases for English-language studies published between January 2009 and August 2020 for current recommendations for predictive scoring tools, fluid management and nutrition, and follow-up and risk-reduction strategies for acute pancreatitis. Several scoring systems, such as the Bedside Index of Severity in Acute Pancreatitis (BISAP) and the Acute Physiology and Chronic Health Evaluation (APACHE) II tools, have good predictive capabilities for disease severity (mild, moderately severe, and severe per the revised Atlanta classification) and mortality, but no one tool works well for all forms of acute pancreatitis. Early and aggressive fluid resuscitation and early enteral nutrition are associated with lower rates of mortality and infectious complications, yet the optimal type and rate of fluid resuscitation have yet to be determined. The underlying etiology of acute pancreatitis should be sought in all patients, and risk-reduction strategies, such as cholecystectomy and alcohol cessation counseling, should be used during and after hospitalization for acute pancreatitis.

Conclusions and Relevance  Acute pancreatitis is a complex disease that varies in severity and course. Prompt diagnosis and stratification of severity influence proper management. Scoring systems are useful adjuncts but should not supersede clinical judgment. Fluid management and nutrition are very important aspects of care for acute pancreatitis.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Mark D. Girgis, MD, University of California, Los Angeles, 10833 Le Conte Ave, 14-174 CHS, Los Angeles, CA 90095 (mdgirgis@mednet.ucla.edu).

Accepted for Publication: September 28, 2020.

Corrections: This article was corrected online June 15, 2021, to fix incorrect positive predictive values reported in the Methods section, and on June 22, 2022, to fix the unit of measure for urine output in the Methods section.

Author Contributions: Drs Mederos and Girgis had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mederos, Reber.

Administrative, technical, or material support: All authors.

Supervision: Reber, Girgis.

Conflict of Interest Disclosures: None reported.

Sellers  ZM , MacIsaac  D , Yu  H ,  et al.  Nationwide trends in acute and chronic pancreatitis among privately insured children and non-elderly adults in the United States, 2007-2014.   Gastroenterology. 2018;155(2):469-478.e1.PubMedGoogle ScholarCrossref
Garg  SK , Sarvepalli  S , Campbell  JP ,  et al.  Incidence, admission rates, and predictors, and economic burden of adult emergency visits for acute pancreatitis.   J Clin Gastroenterol. 2019;53(3):220-225.PubMedGoogle ScholarCrossref
Brindise  E , Elkhatib  I , Kuruvilla  A , Silva  R .  Temporal trends in incidence and outcomes of acute pancreatitis in hospitalized patients in the United States from 2002 to 2013.   Pancreas. 2019;48(2):169-175.PubMedGoogle ScholarCrossref
Gapp  J , Hall  AG , Walters  RW , Jahann  D , Kassim  T , Reddymasu  S .  Trends and outcomes of hospitalizations related to acute pancreatitis: epidemiology from 2001 to 2014 in the United States.   Pancreas. 2019;48(4):548-554.PubMedGoogle ScholarCrossref
Forsmark  CE , Vege  SS , Wilcox  CM .  Acute pancreatitis.   N Engl J Med. 2016;375(20):1972-1981.PubMedGoogle ScholarCrossref
Krishna  SG , Kamboj  AK , Hart  PA , Hinton  A , Conwell  DL .  The changing epidemiology of acute pancreatitis hospitalizations.   Pancreas. 2017;46(4):482-488.PubMedGoogle ScholarCrossref
Lankisch  PG , Apte  M , Banks  PA .  Acute pancreatitis.   Lancet. 2015;386(9988):85-96.PubMedGoogle ScholarCrossref
Roxvall  L , Bengtson  A , Sennerby  L , Heideman  M .  Activation of the complement cascade by trypsin.   Biol Chem Hoppe Seyler. 1991;372(4):273-278.PubMedGoogle Scholar
Uehara  S , Honjyo  K , Furukawa  S , Hirayama  A , Sakamoto  W .  Role of the kallikrein-kinin system in human pancreatitis.   Adv Exp Med Biol. 1989;247B:643-648.PubMedGoogle Scholar
Harvey  MH , Wedgwood  KR , Austin  JA , Reber  HA .  Pancreatic duct pressure, duct permeability and acute pancreatitis.   Br J Surg. 1989;76(8):859-862.PubMedGoogle ScholarCrossref
Krüger  B , Albrecht  E , Lerch  MM .  The role of intracellular calcium signaling in premature protease activation and the onset of pancreatitis.   Am J Pathol. 2000;157(1):43-50.PubMedGoogle ScholarCrossref
Li  J , Zhou  R , Zhang  J , Li  ZF .  Calcium signaling of pancreatic acinar cells in the pathogenesis of pancreatitis.   World J Gastroenterol. 2014;20(43):16146-16152.PubMedGoogle ScholarCrossref
Kochar  B , Akshintala  VS , Afghani  E ,  et al.  Incidence, severity, and mortality of post-ERCP pancreatitis.   Gastrointest Endosc. 2015;81(1):143-149.e9.PubMedGoogle ScholarCrossref
Wang  KX , Ben  QW , Jin  ZD ,  et al.  Assessment of morbidity and mortality associated with EUS-guided FNA.   Gastrointest Endosc. 2011;73(2):283-290.PubMedGoogle ScholarCrossref
Zilio  MB , Eyff  TF , Azeredo-Da-Silva  ALF , Bersch  VP , Osvaldt  AB .  A systematic review and meta-analysis of the aetiology of acute pancreatitis.   HPB (Oxford). 2019;21(3):259-267.PubMedGoogle ScholarCrossref
Papachristou  GI , Machicado  JD , Stevens  T ,  et al.  Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience (APPRENTICE).   Ann Gastroenterol. 2017;30(1):106-113.PubMedGoogle Scholar
Nitsche  C , Maertin  S , Scheiber  J , Ritter  CA , Lerch  MM , Mayerle  J .  Drug-induced pancreatitis.   Curr Gastroenterol Rep. 2012;14(2):131-138.PubMedGoogle ScholarCrossref
Simons-Linares  CR , Elkhouly  MA , Salazar  MJ .  Drug-induced acute pancreatitis in adults: an update.   Pancreas. 2019;48(10):1263-1273.PubMedGoogle ScholarCrossref
Foster  BR , Jensen  KK , Bakis  G , Shaaban  AM , Coakley  FV .  Revised Atlanta classification for acute pancreatitis: a pictorial essay.   Radiographics. 2016;36(3):675-687.PubMedGoogle ScholarCrossref
Banks  PA , Bollen  TL , Dervenis  C ,  et al; Acute Pancreatitis Classification Working Group.  Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus.   Gut. 2013;62(1):102-111.PubMedGoogle ScholarCrossref
Párniczky  A , Kui  B , Szentesi  A ,  et al; Hungarian Pancreatic Study Group.  Prospective, multicentre, nationwide clinical data from 600 cases of acute pancreatitis.   PLoS One. 2016;11(10):e0165309.PubMedGoogle Scholar
Gao  W , Yang  HX , Ma  CE .  The value of BISAP Score for predicting mortality and severity in acute pancreatitis.   PLoS One. 2015;10(6):e0130412.PubMedGoogle Scholar
Ranson  JH , Rifkind  KM , Roses  DF , Fink  SD , Eng  K , Localio  SA .  Objective early identification of severe acute pancreatitis.   Am J Gastroenterol. 1974;61(6):443-451.PubMedGoogle Scholar
Ranson  JH , Pasternack  BS .  Statistical methods for quantifying the severity of clinical acute pancreatitis.   J Surg Res. 1977;22(2):79-91.PubMedGoogle ScholarCrossref
Blamey  SL , Imrie  CW , O’Neill  J , Gilmour  WH , Carter  DC .  Prognostic factors in acute pancreatitis.   Gut. 1984;25(12):1340-1346.PubMedGoogle ScholarCrossref
Imrie  CW , Benjamin  IS , Ferguson  JC ,  et al.  A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis.   Br J Surg. 1978;65(5):337-341.PubMedGoogle ScholarCrossref
Knaus  WA , Draper  EA , Wagner  DP , Zimmerman  JE .  APACHE II: a severity of disease classification system.   Crit Care Med. 1985;13(10):818-829.PubMedGoogle ScholarCrossref
Wu  BU , Johannes  RS , Sun  X , Tabak  Y , Conwell  DL , Banks  PA .  The early prediction of mortality in acute pancreatitis.   Gut. 2008;57(12):1698-1703.PubMedGoogle ScholarCrossref
Singh  VK , Wu  BU , Bollen  TL ,  et al.  A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis.   Am J Gastroenterol. 2009;104(4):966-971.PubMedGoogle ScholarCrossref
Stirling  AD , Moran  NR , Kelly  ME , Ridgway  PF , Conlon  KC .  The predictive value of C-reactive protein (CRP) in acute pancreatitis.   HPB (Oxford). 2017;19(10):874-880.PubMedGoogle ScholarCrossref
Taydas  O , Unal  E , Karaosmanoglu  AD , Onur  MR , Akpinar  E .  Accuracy of early CT findings for predicting disease course in patients with acute pancreatitis.   Jpn J Radiol. 2018;36(2):151-158.PubMedGoogle ScholarCrossref
Sahu  B , Abbey  P , Anand  R , Kumar  A , Tomer  S , Malik  E .  Severity assessment of acute pancreatitis using CT Severity Index and modified CT Severity Index: correlation with clinical outcomes and severity grading as per the Revised Atlanta Classification.   Indian J Radiol Imaging. 2017;27(2):152-160.PubMedGoogle Scholar
Busireddy  KK , AlObaidy  M , Ramalho  M ,  et al.  Pancreatitis-imaging approach.   World J Gastrointest Pathophysiol. 2014;5(3):252-270.PubMedGoogle ScholarCrossref
Thoeni  RF .  The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment.   Radiology. 2012;262(3):751-764.PubMedGoogle ScholarCrossref
Wu  BU , Johannes  RS , Sun  X , Conwell  DL , Banks  PA .  Early changes in blood urea nitrogen predict mortality in acute pancreatitis.   Gastroenterology. 2009;137(1):129-135.PubMedGoogle ScholarCrossref
Wu  BU , Bakker  OJ , Papachristou  GI ,  et al.  Blood urea nitrogen in the early assessment of acute pancreatitis.   Arch Intern Med. 2011;171(7):669-676.PubMedGoogle ScholarCrossref
Working Group IAP/APA Acute Pancreatitis Guidelines.  IAP/APA evidence-based guidelines for the management of acute pancreatitis.   Pancreatology. 2013;13(4)(suppl 2):e1-e15.PubMedGoogle ScholarCrossref
Crockett  SD , Wani  S , Gardner  TB , Falck-Ytter  Y , Barkun  AN ; American Gastroenterological Association Institute Clinical Guidelines Committee.  American Gastroenterological Association Institute guideline on initial management of acute pancreatitis.   Gastroenterology. 2018;154(4):1096-1101.PubMedGoogle ScholarCrossref
Vivian  E , Cler  L , Conwell  D ,  et al.  Acute Pancreatitis Task Force on Quality.   Am J Gastroenterol. 2019;114(8):1322-1342.PubMedGoogle ScholarCrossref
Ketwaroo  G , Sealock  RJ , Freedman  S ,  et al.  Quality of care indicators in patients with acute pancreatitis.   Dig Dis Sci. 2019;64(9):2514-2526.PubMedGoogle ScholarCrossref
Iqbal  U , Anwar  H , Scribani  M .  Ringer’s lactate versus normal saline in acute pancreatitis.   J Dig Dis. 2018;19(6):335-341.PubMedGoogle ScholarCrossref
Choosakul  S , Harinwan  K , Chirapongsathorn  S ,  et al.  Comparison of normal saline versus Lactated Ringer’s solution for fluid resuscitation in patients with mild acute pancreatitis.   Pancreatology. 2018;S1424-3903(18)30083-8.PubMedGoogle Scholar
Mao  EQ , Fei  J , Peng  YB , Huang  J , Tang  YQ , Zhang  SD .  Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis.   Chin Med J (Engl). 2010;123(13):1639-1644.PubMedGoogle Scholar
Wu  LM , Sankaran  SJ , Plank  LD , Windsor  JA , Petrov  MS .  Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis.   Br J Surg. 2014;101(13):1644-1656.PubMedGoogle ScholarCrossref
Al-Omran  M , Albalawi  ZH , Tashkandi  MF , Al-Ansary  LA .  Enteral versus parenteral nutrition for acute pancreatitis.   Cochrane Database Syst Rev. 2010;(1):CD002837.PubMedGoogle Scholar
Qi  D , Yu  B , Huang  J , Peng  M .  Meta-analysis of early enteral nutrition provided within 24 hours of admission on clinical outcomes in acute pancreatitis.   JPEN J Parenter Enteral Nutr. 2018;42(7):1139-1147.PubMedGoogle ScholarCrossref
Meng  WB , Li  X , Li  YM , Zhou  WC , Zhu  XL .  Three initial diets for management of mild acute pancreatitis: a meta-analysis.   World J Gastroenterol. 2011;17(37):4235-4241.PubMedGoogle ScholarCrossref
Bakker  OJ , van Brunschot  S , van Santvoort  HC ,  et al; Dutch Pancreatitis Study Group.  Early versus on-demand nasoenteric tube feeding in acute pancreatitis.   N Engl J Med. 2014;371(21):1983-1993.PubMedGoogle ScholarCrossref
Dutta  AK , Goel  A , Kirubakaran  R , Chacko  A , Tharyan  P .  Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis.   Cochrane Database Syst Rev. 2020;3:CD010582.PubMedGoogle Scholar
Arvanitakis  M , Ockenga  J , Bezmarevic  M ,  et al.  ESPEN guideline on clinical nutrition in acute and chronic pancreatitis.   Clin Nutr. 2020;39(3):612-631.PubMedGoogle ScholarCrossref
Poropat  G , Giljaca  V , Hauser  G , Štimac  D .  Enteral nutrition formulations for acute pancreatitis.   Cochrane Database Syst Rev. 2015;(3):CD010605.PubMedGoogle Scholar
van Baal  MC , Besselink  MG , Bakker  OJ ,  et al; Dutch Pancreatitis Study Group.  Timing of cholecystectomy after mild biliary pancreatitis: a systematic review.   Ann Surg. 2012;255(5):860-866.PubMedGoogle ScholarCrossref
Hwang  SS , Li  BH , Haigh  PI .  Gallstone pancreatitis without cholecystectomy.   JAMA Surg. 2013;148(9):867-872.PubMedGoogle ScholarCrossref
Aboulian  A , Chan  T , Yaghoubian  A ,  et al.  Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study.   Ann Surg. 2010;251(4):615-619.PubMedGoogle ScholarCrossref
Dubina  ED , de Virgilio  C , Simms  ER , Kim  DY , Moazzez  A .  Association of early vs delayed cholecystectomy for mild gallstone pancreatitis with perioperative outcomes.   JAMA Surg. 2018;153(11):1057-1059.PubMedGoogle ScholarCrossref
Falor  AE , de Virgilio  C , Stabile  BE ,  et al.  Early laparoscopic cholecystectomy for mild gallstone pancreatitis.   Arch Surg. 2012;147(11):1031-1035.PubMedGoogle ScholarCrossref
Mueck  KM , Wei  S , Pedroza  C ,  et al.  Gallstone Pancreatitis: Admission Versus Normal Cholecystectomy: a randomized trial (Gallstone PANC Trial).   Ann Surg. 2019;270(3):519-527.PubMedGoogle Scholar
Nealon  WH , Bawduniak  J , Walser  EM .  Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections.   Ann Surg. 2004;239(6):741-749.PubMedGoogle ScholarCrossref
Magnusdottir  BA , Baldursdottir  MB , Kalaitzakis  E , Björnsson  ES .  Risk factors for chronic and recurrent pancreatitis after first attack of acute pancreatitis.   Scand J Gastroenterol. 2019;54(1):87-94.PubMedGoogle ScholarCrossref
Nordback  I , Pelli  H , Lappalainen-Lehto  R , Järvinen  S , Räty  S , Sand  J .  The recurrence of acute alcohol-associated pancreatitis can be reduced.   Gastroenterology. 2009;136(3):848-855.PubMedGoogle ScholarCrossref
Ahmed Ali  U , Issa  Y , Hagenaars  JC ,  et al; Dutch Pancreatitis Study Group.  Risk of recurrent pancreatitis and progression to chronic pancreatitis after a first episode of acute pancreatitis.   Clin Gastroenterol Hepatol. 2016;14(5):738-746.PubMedGoogle ScholarCrossref
Hollemans  RA , Hallensleben  NDL , Mager  DJ ,  et al; Dutch Pancreatitis Study Group.  Pancreatic exocrine insufficiency following acute pancreatitis.   Pancreatology. 2018;18(3):253-262.PubMedGoogle ScholarCrossref
Huang  W , de la Iglesia-García  D , Baston-Rey  I ,  et al.  Exocrine pancreatic insufficiency following acute pancreatitis.   Dig Dis Sci. 2019;64(7):1985-2005.PubMedGoogle ScholarCrossref
Zhi  M , Zhu  X , Lugea  A , Waldron  RT , Pandol  SJ , Li  L .  Incidence of new onset diabetes mellitus secondary to acute pancreatitis.   Front Physiol. 2019;10:637.PubMedGoogle ScholarCrossref
Sarr  MG .  2012 revision of the Atlanta classification of acute pancreatitis.   Pol Arch Med Wewn. 2013;123(3):118-124.PubMedGoogle Scholar
Loveday  BP , Srinivasa  S , Vather  R ,  et al.  High quantity and variable quality of guidelines for acute pancreatitis: a systematic review.   Am J Gastroenterol. 2010;105(7):1466-1476.PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.