Acute pancreatitis management depends on repeated decisions: whether the diagnosis is secure, whether organ dysfunction is emerging, how much fluid the patient needs, and when an intervention will help. The 2026 iLATAM-AP guideline brings medical, endoscopic and surgical care into one framework. Its central bedside priorities are moderate, reassessed resuscitation; feeding when tolerated; selective ERCP; and proportionate intervention for complications.
This article reviews selected recommendations for adult clinical practice. It is an independent educational interpretation of the guideline, rather than a complete protocol or a claim that every recommendation is new in 2026. References to clinical questions below identify the relevant sections of the original guideline .
What is the source—and how current is its evidence?
The AEG-AESPANC-OPGE-SIED-SPG Ibero-Latin American Guidelines on Acute Pancreatitis (iLATAM-AP) were first published on 30 May 2026 in the United European Gastroenterology Journal. They address 20 clinical questions, using systematic reviews, GRADE assessment and expert consensus across the Iberian Peninsula and Latin America.
The prespecified literature search covered January 1979 to March 2024, with observational evidence considered where higher-quality studies were unavailable. Publication in 2026 therefore does not mean that every recommendation incorporates all evidence published during 2026. Local services, antimicrobial policies and access to specialist endoscopy remain relevant to implementation.
Confirm the diagnosis without making imaging automatic
Acute pancreatitis requires at least two of three features: characteristic abdominal pain; serum lipase and/or amylase activity more than three times the upper limit of normal; or characteristic imaging. Typical pain with the qualifying enzyme elevation can establish the diagnosis without diagnostic CT. Imaging is particularly useful when the presentation is atypical or the diagnosis remains uncertain. These are strong recommendations, supported by moderate-quality evidence for the diagnostic criteria and low-quality evidence for the selective imaging approach. Q2
Investigate the cause alongside initial treatment. The guideline recommends a history, examination, liver profile, triglycerides, calcium and abdominal ultrasound. Review alcohol exposure, gallstones, medicines and other plausible causes. If no cause emerges, repeat assessment and consider endoscopic ultrasound (EUS) and/or magnetic resonance cholangiopancreatography (MRCP); one unrevealing ultrasound does not establish idiopathic disease. Pancreas-protocol contrast CT is an alternative when advanced tests are unavailable or malignancy is suspected. Q3–Q4
Classify severity—and reassess the trajectory
Use the Revised Atlanta framework. Organ failure and complications determine severity; a reassuring first assessment does not fix the category for the rest of the admission. Q6
| Category | Defining features | Bedside implication |
|---|---|---|
| Mild | No organ failure and no local or systemic complications | Continue supportive care and cause-specific planning; reassess if the course changes. |
| Moderately severe | Transient organ failure resolving within 48 hours and/or local or systemic complications, without persistent organ failure | Monitor closely and arrange complication-specific assessment. |
| Severe | Persistent organ failure for more than 48 hours, affecting one or more systems | Intensive care and multidisciplinary management are required. |
Do not wait 48 hours to escalate a deteriorating patient. The duration threshold defines severe disease; it is not a waiting period before critical care referral. Early ICU admission is advised for organ failure unresponsive to initial resuscitation or infected pancreatic necrosis with systemic compromise. Persistent single or multiple organ failure also warrants ICU care. Q7
Intermediate care is recommended for predicted severe disease, such as BISAP ≥3 or persistent systemic inflammatory response syndrome (SIRS), and for isolated organ failure that responds to initial treatment without pancreatic infection. Where intermediate care is unavailable, close monitoring is essential. These level-of-care recommendations are strong, with moderate-quality evidence.
Prescribe moderate fluids, then adjust to response
The guideline recommends lactated Ringer’s solution, with a moderate infusion rate of 1.5 mL/kg/hour. For signs of hypovolaemia at admission, it specifies 10 mL/kg over two hours before the infusion; a bolus may be repeated if hypovolaemia persists or subsequently develops. Reduce or discontinue fluid if overload develops. The moderate-fluid strategy is a strong recommendation with high-quality evidence; the preference for lactated Ringer’s is strong with moderate-quality evidence. Q8
These numbers describe a starting strategy, not a fixed-volume target for every patient. At the bedside, individualise treatment to perfusion, fluid balance and tolerance, particularly in cardiac or renal disease. Shock, worsening respiratory status or continuing oliguria should prompt reassessment of the cause and need for organ support, rather than repeated fluid administration without review. This is a practical implementation principle, not a separate guideline dosing regimen.
Treat pain and avoid unnecessary fasting
Use multimodal analgesia according to pain intensity, comorbidities and clinical response. Paracetamol and/or an NSAID may be adequate for mild pain; opioids may be needed for more severe pain. NSAIDs require caution or avoidance in acute or chronic renal failure. De-escalate analgesia as recovery permits. Q9
Offer oral feeding within 24–48 hours when the patient feels able to eat, including in predicted severe disease. In mild pancreatitis, a soft or solid diet may be started immediately if tolerated; a compulsory clear-fluid sequence is unnecessary. If oral intake remains intolerable 3–4 days after disease onset, nasogastric enteral nutrition is preferred. Reserve nasojejunal feeding for impaired gastric emptying, proximal obstruction or high aspiration risk, and parenteral nutrition for situations in which oral and enteral routes are not feasible. These nutrition recommendations are strong with high-quality evidence. Q12
Use antibiotics for infection, not sterile necrosis
Necrosis alone is not an indication for prophylactic antibiotics. Treat suspected or confirmed infected pancreatic necrosis, acute cholangitis or another bacterial infection. The recommendations against routine prophylaxis and for infection-directed treatment are strong with high-quality evidence. Procalcitonin may help guide antibiotic use, but should support the clinical assessment. Antifungal prophylaxis is not advised. Q10
In practice, select antimicrobial treatment with the infection site, cultures, local susceptibility patterns, organ function and source-control plan in mind. Fever or inflammatory markers alone should not automatically convert sterile inflammation into a diagnosis of infected necrosis.
Separate urgent ERCP from evaluation of retained stones
| Clinical situation | Guideline approach |
|---|---|
| Biliary pancreatitis with acute cholangitis | Urgent ERCP within 24 hours: strong recommendation, high-quality evidence. |
| Choledocholithiasis without cholangitis | ERCP may be delayed; routine early ERCP has not improved outcomes: weak recommendation, moderate-quality evidence. |
| Uncertain retained duct stone | Use EUS or MRCP when indicated, rather than treating ERCP as a routine diagnostic test. |
| Persistent/progressive cholestasis or duct dilation without cholangitis | In clinically stable patients, assessment for choledocholithiasis may be deferred for up to one week: weak recommendation, low-quality evidence. |
Severe pancreatitis by itself does not establish a benefit from urgent ERCP. Continued biliary obstruction still needs specialist assessment and a therapeutic plan; “no routine early ERCP” does not mean that confirmed retained stones should be ignored. The option to defer assessment applies to a stable patient without cholangitis, not to someone deteriorating with suspected biliary sepsis. Q13 and Q19
Manage collections according to indication, timing and response
Most pancreatic or peripancreatic collections resolve without intervention. CT helps identify collections; MRI can clarify fluid and solid components when needed. A collection on imaging is not, by itself, a drainage indication. Q16
When intervention is necessary, the guideline favours waiting at least four weeks when clinically feasible. Reasons to intervene include infection not responding to antibiotics, persistent SIRS or organ failure, sepsis, refractory pain, obstruction and other consequential complications. Delay should never become a reason to withhold necessary source control from a deteriorating patient.
| Step | What guides the next action? |
|---|---|
| Observe or treat infection when present | Follow the clinical course; avoid intervening solely because a collection exists. |
| Drain when indicated | Prefer endoscopic drainage when feasible. Percutaneous drainage is useful when early intervention is unavoidable or the anatomy/access requires it. |
| Reassess after drainage | Improvement may avoid necrosectomy. Endoscopic necrosectomy is reserved for failure to improve or deterioration. |
| Escalate if less invasive approaches fail | Minimally invasive surgical necrosectomy is preferred to open surgery when appropriate. |
The delay and step-up recommendations have high-quality evidence for several key decisions, but selection of access and procedure depends on anatomy, timing and expertise. Refer complicated necrotising disease early to a multidisciplinary centre with endoscopic, radiological, surgical and critical-care capability.
Prevent recurrence with appropriate cholecystectomy timing
For mild biliary pancreatitis, laparoscopic cholecystectomy should occur during the index admission: a strong recommendation with high-quality evidence. This is definitive prevention of further gallstone-related episodes, rather than an optional follow-up detail. Q18
For moderately severe or severe biliary disease, the guideline recommends delay until local complications resolve or around eight weeks after discharge. This is a weak recommendation with low-quality evidence. Its discussion particularly supports waiting for collections to resolve when present; timing otherwise requires recovery-based surgical review. Do not apply the same-admission pathway for mild disease indiscriminately to necrotising or complicated pancreatitis.
Plan recovery beyond discharge
Document the cause, recurrence-prevention plan, nutritional recovery and arrangements for complications. The guideline suggests evaluating exocrine and endocrine pancreatic function particularly after necrotising, alcohol-associated or recurrent pancreatitis, and after necrosectomy. Faecal elastase is a first-line exocrine screening test; glucose-based testing should also be considered in patients with metabolic risk factors. Q20
For at-risk patients, the authors propose assessment at 3, 6 and 12 months, then every 6–12 months if dysfunction persists. These are weak recommendations with low-quality evidence, not a universally validated surveillance schedule. Symptoms of maldigestion, nutritional status and evolving hyperglycaemia should guide follow-up alongside tests.
What should change on the next ward round?
Confirm the diagnosis, identify the cause and reassess organ function. Give fluids according to current need and tolerance. Feed when tolerated, identify infection before prescribing antibiotics, and reserve urgent ERCP for the appropriate biliary indication. If complications develop, ask what intervention is needed now, what can safely wait and which specialist team should be involved.
The useful organising principle is reassessment linked to action: the initial severity label, fluid prescription or CT appearance should never substitute for the patient’s evolving clinical course.
Original guideline
Cárdenas-Jaén K, Guilabert L, Martínez-Moneo E, et al. AEG-AESPANC-OPGE-SIED-SPG Ibero-Latin American Guidelines on Acute Pancreatitis (iLATAM-AP). United European Gastroenterology Journal. 2026;14(5):e70190. First published 30 May 2026. doi:10.1002/ueg2.70190 . Open-access full text .
This summary selects practical recommendations from the source; it does not reproduce its full 20-question guidance, including detailed management of splanchnic thrombosis, abdominal compartment syndrome and disconnected pancreatic duct syndrome. Consult the original document for those decisions. Cover: AI-generated conceptual anatomical illustration.