Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Diagnose clinically with labs; risk-stratify.
- Start LR fluids, analgesia, and early enteral feeding as needed; avoid prophylactic antibiotics.
- For gallstone pancreatitis: early cholecystectomy in mild cases; ERCP only if cholangitis or persistent obstruction.
Clinical Synopsis & Reasoning
Epigastric pain radiating to the back with elevated lipase/amylase (>3× ULN) and imaging findings. Provide early goal-directed fluids (prefer lactated Ringer’s), adequate analgesia, and early enteral nutrition; avoid prophylactic antibiotics. Identify gallstone etiology and perform cholecystectomy before discharge for mild cases.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Serum lipase (preferred) ± amylase | Diagnosis | >3× ULN | Lipase more specific |
| Contrast-enhanced CT (after 48–72 h if severe) | Severity/complications | Necrosis/collections | Avoid early CT in mild |
| BISAP/APACHE II scores | Risk stratification | Predict severe disease | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Persistent organ failure (Marshall score) or necrosis | Severe disease | ICU; step-up drainage/necrosectomy strategy |
| Gallstone pancreatitis with cholangitis/obstruction | Source control needed | Urgent ERCP |
| Refractory pain or feeding intolerance | Complications/nutrition risk | Early enteral feeding via NJ; pain plan |
| Infected necrosis suspected (gas on CT) | Sepsis risk | Antibiotics active against gut flora; drainage |
| Hypertriglyceridemia >1000 mg/dL | Etiology needing specific care | Insulin/heparin ± plasmapheresis |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Lactated Ringer’s 250–500 mL/h (titrate) | Fluids | Hours | Reduce SIRS | Avoid fluid overload |
| Opioid/adjunct analgesia and antiemetics | Symptom control | Minutes-hours | Comfort and reduce ileus | — |
| Enteral nutrition (NG/NJ) within 24–48 h if severe | Nutrition | Hours-days | Maintains gut barrier | Avoid parenteral unless necessary |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACG guideline on acute pancreatitis — Link