Introduction

Acute pancreatitis is often managed clinically, not only by specialists in surgery, internal medicine, and emergency medicine but also by general physicians, gastroenterologists, and general surgeons. Consequently, the Guidelines have been prepared in order to help these physicians to diagnose acute pancreatitis accurately and to manage patients by means of an appropriate treatment policy, thus improving survival rates. According to the available literature, the mortality rate for patients with severe acute pancreatitis ranged between 30% and 21.4% from 1987 to 1999. Which cases are likely to be fatal? Which categories of morbidity are likely to become more severe? And under what circumstances should patients be transferred to a special hospital? There is a great need for Guidelines that clearly answer these and other questions.

Several sets of evidence-based guidelines for the management of acute pancreatitis have been published; those of the Atlanta Symposium of 1992,1 the United Kingdom Guidelines of 1998,2 and the Santorini Consensus Conference of 19993 are representative. However, they were based on the evidence available at the time, and the validity of any set of guidelines is shortlived and guidelines need to be revised every 2 years.1 Indeed, new evidence is reported almost daily, and guidelines for management in clinical settings are changing nearly as fast, thanks to the remarkable advances in medical equipment and treatment techniques developed in recent years. The International Association of Pancreatology guidelines4 were most recently published in 2002, but they are concerned solely with the surgical management of acute pancreatitis.

The Guidelines Publishing Committee very much hopes that this publication will help clinicians worldwide to become familiar with the Guidelines, and the Committee hopes that those professionals will offer their comments and criticisms once they have had the opportunity to compare them with the guidelines in use in their own countries.

Purpose of the Guidelines

The mortality rate among patients with severe acute pancreatitis remains high, although various current diagnostic criteria, methods of severity assessment, and new treatments have been used at a number of institutions. However, there are inter-institutional differences in the ways in which the disease is managed, due to the lack of evidence-based guidelines.

In view of this situation, the Guidelines have been formulated with the aim of providing practical management guidelines to clinicians engaged in the management of acute pancreatitis. The Working Group has striven to ensure that the Guidelines will help general clinicians not only to assess the severity of acute pancreatitis promptly but also to manage the disease appropriately and efficiently. The Guidelines should also help patients, their families, and the general public to acquire better knowledge of acute pancreatitis, and thereby lead to a better standard of medical management based on mutual understanding between those who provide medical treatment and those who receive it.

How the Guidelines were formulated

With evidence-based medicine (EBM) as the core concept, an initial draft of the Guidelines was prepared by members of the Guidelines Preparation Committee and the Working Group, both of which consisted of specialists from the Japanese Society of Abdominal Emergency Medicine, who searched the available documents and evaluated the evidence they found there5. Following this process, a Guidelines Investigation Committee — consisting of members of the Working Group, the Japan Pancreas Society, and the Research Group for Intractable Diseases and Refractory Pancreatic Diseases — was formed to examine the draft Guidelines.

In addition to the Investigation Committee, an Evaluation Committee — whose members were drawn from the Japanese Society of Abdominal Emergency Medicine, the Japanese Ministry of Health, Labour, and Welfare, and several external institutions — was formed to critique the Guidelines whenever necessary.

Defining and extending the search of the literature

Works were selected as follows. Using “pancreatitis” as the key search word, a MeSH-based exploration of the Ovid Medline database (1960–2004) yielded approximately 28000 items under the headings “pancreatitis”, “acute necrotizing pancreatitis,” and “alcoholic pancreatitis.” The items were then screened to confine the entries to those related to human pancreatitis. This yielded 14821 items in English, and after examination of all the titles and abstracts, 1348 were selected, and a careful examination of the full texts was conducted. Other sources quoted in these selected works, together with works suggested by the specialist members, as well as reports prepared by the Research Group, were included in the examination.

Categories of evidence and the grading of recommendations

The evidence obtained from each reference item was evaluated in accordance with the scientific classification method used at the Cochrane Library (Table 1),6 and the quality of evidence for each parameter associated with the diagnosis and treatment of acute pancreatitis was determined. The relevant terms used are explained the footnote of Table 1.6 Based on the results obtained from these procedures, recommendation grades of A to E, were determined according to the definitions shown in Table 2, and these recommendation grades are mentioned, as required, in the text of the Guidelines. The grading is based on the Kish7 method of classification.

Table 1 Categories of evidence (see footnote for explanation of terms).6 The evidence-based classification used at the Cochrane Library: Oxford Centre for Evidence-based Medicine, Levels of Evidence (May 2001) (http://www.cebm.net/levels_of_evidence.asp#levels)5 was used as a basis to evaluate evidence presented in each item of literature, and the quality of evidence for each parameter associated with the diagnosis and treatment of acute pancreatitis was determined
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Table 2 Japan Abdominal Emergency Society Grading System for ranking the recommendations in the clinical Guidelines
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Recommendations graded as either A or B indicate high quality. However, those graded as D or E are considered to be unacceptable. It must be borne in mind that such recommendation grades merely represent standards and should not be used to compel adherence to a given method of medical management in an actual clinical setting. The medical management method that is applied should be selected after taking into account the conditions prevailing in the relevant institution (staff, experience, equipment, etc.) and the characteristics of the individual patient.

Notes on the use of the Guidelines

The Guidelines are evidence-based and determined with a grade for each medical practice, taking actual conditions into account. The Guidelines specify the criteria for the diagnosis of acute pancreatitis and the assessment of its severity that have been prepared by the Research Group and are in widespread use in Japan. Because the Guidelines address so many different topics, an index of all works used is included at the end of the series of articles for the convenience of readers. The dosages described in the text of the Guidelines are for adult patients.