The consensus of integrative diagnosis and treatment of acute pancreatitis‐2017

Abstract

Acute pancreatitis (AP) is one of the most common acute abdominal diseases. The digestive disease committee, Chinese Association of Integrative Medicine, released Integrated traditional Chinese and Western medicine for diagnosis and treatment of acute pancreatitis in 2010.1 Since then, further studies and great progress have been made by domestic and foreign counterparts from the perspective of both Chinese and Western medicine in AP, including the classification, fluid resuscitation, organ function maintenance, surgery intervention, enteral nutrition (EN), and syndrome differentiation and treatment. It is necessary to update the consensus on diagnosis and treatment of integrated Chinese and Western medicine to meet clinical needs. Therefore, the 2012 Revision of the Atlanta Classification Standard (RAC) by the International AP Consensus,2 the 2013 the Management of Acute Pancreatitis by the American College of Gastroenterology,3, 4 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 Pancreatitis 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.

Appraisal of the diagnostic procedures of acute pancreatitis in the guidelines

“…Two of the articles [2,6] were from Italy, three [3,7,8] were from China, and the remaining two were from Japan and Canada [4,5]. One article [2] presented the original version of the guidelines, and the remaining six [3,4,5,6,7,8] presented updated versions that improved and extended the guidelines. Of the seven included guides, ve guides used three grading systems to rate the level of evidence and the strength of the recommendation (Table 1); 3 [2,5,8] adopted the GRADE system, one [6] used the APACHE system, and one used the Delphi classi cation standard [7].…”

“…These guidelines fell into the recommended category, but they still need to be improved. Two guidelines had a total score of less than 30% [3,8], and so they could not be recommended. It is worth noting that there were two guidelines with relatively high scores (exceeding 60%) in each area except the Applicability domain [2,5],which were classi ed according to the recommendations of clinical practice developed by the World Society of Emergency Surgery (WSES) and the Japanese Society of Hepato-Biliary-Pancreatic Surgery, respectively.…”

“…(1) Primary diagnosis of AP Four guidelines [2,3,7,8] recommend abdominal pain as a reference indicator for the diagnosis of severe pancreatitis; the other three only mention the symptom. The recommendations of the three guidelines [3,7,8] for abdominal pain (sustained attacks, severe and acute episodes of epigastric pain usually radiating to the back) had a high similarity (80% -100%) to the reference recommendations. The cited levels of evidence were only grade 5 [2,7].…”

“…Six guidelines [2,3,4,5,7,8] recommend serum lipase activity (or amylase) at least three times the upper normal limit as a reference indicator for the diagnosis of severe pancreatitis, among which three guidelines make an explicit recommendation [4,5,8], while the remaining three guidelines only casually recommend it [2,3,7]. Five guidelines [3,4,5,7,8] recommending serum lipase activity (or amylase) at least three times the upper normal limit had a high degree of similarity (80% -100%) to the reference recommendation, and the reference level of evidence was up to grade 4 [4,8]. In six guidelines [1,2,3,4,5,7,8], the characteristics of abdominal imaging are recommended as reference indicators for the diagnosis of severe pancreatitis.…”

“…Five guidelines [3,4,5,7,8] recommending serum lipase activity (or amylase) at least three times the upper normal limit had a high degree of similarity (80% -100%) to the reference recommendation, and the reference level of evidence was up to grade 4 [4,8]. In six guidelines [1,2,3,4,5,7,8], the characteristics of abdominal imaging are recommended as reference indicators for the diagnosis of severe pancreatitis. Three of these guidelines make explicit recommendations [4,5,8], and the remaining three guidelines merely mentioned these characteristics in the content [2,3,7].…”