gastroenterology American College of Gastroenterology GuidelineManagement of Acute Pancreatitis_图文.docVIP

gastroenterology American College of Gastroenterology GuidelineManagement of Acute Pancreatitis_图文 T enner et al. In the majority of patients with gallstone pancreatitis, the common bile duct stone passes to the duodenum. Routine ERCP is not appropriate unless there is a high suspicion of a persis-tent common bile duct stone, manifested by an elevation in the bilirubin ( 151 ). Patients with mild AP, with normal bilirubin, can undergo laproscopic cholecystectomy with intraoperative cholangio graphy, and any remaining bile duct stones can be dealt with by postoperative or intraoperative ERCP. In patients with low to moderate risk, MRCP or EUS can be used preoperatively, but routine use of MRCP is unnecessary. In patients with mild AP who cannot undergo surgery, such as the frail elderly and / or those with severe comorbid disease, biliary sphincterotomy alone may be an eff ective way to reduce further attacks of AP, although attacks of cholecystitis may still occur ( 53 ). D EBRIDEMENT OF NECROSIS Historically, open necrosectomy / debridement was the treatment of choice for infected necrosis and symptomatic sterile necrosis. Decades ago, patients with sterile necrosis underwent early debri-dement that resulted in increased mortality. For this reason, early open debridement for sterile necrosis was abandoned ( 32 ). How-ever, debridement for sterile necrosis is recommended if associ-ated with gastric outlet obstruction and / or bile duct obstruction. In patients with infected necrosis, it was falsely believed that mortality of infected necrosis was nearly 100 % if debridement was not performed urgently ( 53,152 ). In a retrospective review of 53 patients with infected necrosis treated operatively (median time to surgery of 28 days) mortality fell to 22 % when necrosec-t