Intended for healthcare professionals

Clinical Review State of the Art Review

Management of severe acute pancreatitis

BMJ 2019; 367 doi: (Published 02 December 2019) Cite this as: BMJ 2019;367:l6227
  1. O Joe Hines, professor and chief1,
  2. Stephen J Pandol, director, basic and translational pancreas research2
  1. 1Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-6904, USA
  2. 2Department of Medicine, Cedar-Sinai Medical Center, Los Angeles, CA 90048, USA
  1. Correspondence to: O J Hines joehines{at}


The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: SJP wrote the sections on the epidemiology, causes, severity assessment, and guidelines of pancreatitis. OJH completed the primary literature review for the manuscript; wrote the sections on early resuscitation, imaging, medical management, and procedural intervention; and serves as the guarantor. Both authors reviewed all sections of the manuscript, providing suggestions for included content and references.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: No patients were asked for input in the creation of this article.

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