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January 16, 2020

AGA Clinical Practice Update: management of pancreatic necrosis

New guidance from AGA offers 15 best practice recommendations for the optimal management of patients with this highly morbid condition.
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If you treat patients with pancreatic necrosis, review AGA’s newest Clinical Practice Update in the January issue of Gastroenterology, which provides 15 expert recommendations regarding the clinical care of your patients with pancreatic necrosis. These best practice advice points, agreed upon by leading experts, reflect landmark and recent published articles in this field.

  • Best Practice Advice 1

    Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists and specialists in critical care medicine, infectious disease and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center.

  • Best Practice Advice 2

    Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (i.e., gas in the collection, bacteremia, sepsis or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended.

  • Best Practice Advice 3

    When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (e.g., carbapenems, quinolones and metronidazole). Routine use of antifungal agents is not recommended. CT–guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases.

  • Best Practice Advice 4

    In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated.

  • Best Practice Advice 5

    Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting and nutritional failure or with associated complications, including gastrointestinal luminal obstruction, biliary obstruction, recurrent acute pancreatitis, fistulas or persistent systemic inflammatory response syndrome.

Read all 15 recommendations in the January of Gastroenterology.

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