Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
Acute pancreatitis is diagnosed by two of three: characteristic epigastric pain, lipase ≥3× normal, and imaging findings. Establish etiology—gallstones, alcohol, hypertriglyceridemia, medications—and assess severity using clinical scores and organ failure. Look for complications (necrosis, fluid collections) and cholangitis requiring urgent intervention.
Treatment Strategy & Disposition
Early aggressive, goal‑directed fluid resuscitation with balanced crystalloids, effective analgesia, and early enteral nutrition are cornerstone therapies. Avoid prophylactic antibiotics; treat infected necrosis when proven. Perform ERCP urgently for gallstone pancreatitis with cholangitis; schedule cholecystectomy during index admission for mild biliary disease. ICU for persistent organ failure; otherwise ward care with frequent reassessment.
Management Notes
Monitor for organ failure and necrosis. Consider ICU for severe disease.
Epidemiology / Risk Factors
- NSAIDs/alcohol; biliary disease
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Bleeding/anemia | Low Hgb | |
| CMP | LFTs/electrolytes | Abnormal LFTs | |
| Lipase (if pancreatitis) | Pancreatic enzyme | Elevated | |
| CT Abd/Pelvis (selected) | Complications | Findings vary |
When to Do ERCP
| Scenario | Action |
|---|---|
| Cholangitis | Urgent ERCP |
| Persistent biliary obstruction (elevated bilirubin/dilated duct) | Early ERCP |
| Gallstone pancreatitis without obstruction | No urgent ERCP |
| Post‑ERCP pancreatitis prevention | Rectal indomethacin in high‑risk ERCP |
| Nutrition | Enteral early; avoid TPN unless needed |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Aggressive isotonic fluids | Volume expansion | Immediate | Early resuscitation | Fluid overload |
| Opioid analgesic | μ-receptor agonism | Minutes | Analgesia | Respiratory depression/ileus |
| Antiemetic (ondansetron) | 5-HT3 antagonism | Minutes | Nausea control | QT prolongation |
Prognosis / Complications
- Varies by etiology and bleeding severity; rebleeding/perforation
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
References
- ACG/AGA Pancreatitis Guidance — Link