Key Points
- Confirm diagnosis early with highest‑yield tests (and do not let testing delay time‑critical therapy).
- Use explicit hemodynamic, respiratory, and neurologic targets to guide escalation.
- Document disposition criteria, follow‑up, and patient education before discharge.
Algorithm
- Resuscitate with balanced crystalloids; monitor urine output and hemodynamics.
- Early enteral nutrition; avoid prolonged NPO/TPN when possible.
- Contrast CT at 72–96 h if severe course to assess necrosis/collections.
- Reserve antibiotics for infected necrosis; obtain cultures when feasible.
- Multidisciplinary review (GI, surgery, IR) for step‑up planning.
- Delay intervention until walled‑off necrosis (~4 weeks) when stable.
- First‑line drainage: percutaneous or endoscopic (LAMS).
- If inadequate → minimally invasive necrosectomy (endoscopic/VARD).
- Manage organ failures (ARDS, AKI); DVT prophylaxis and nutrition optimization.
- Plan staged re‑interventions based on clinical and imaging response.
Clinical Synopsis & Reasoning
Severe pancreatitis complicated by necrosis requires early enteral nutrition, goal‑directed resuscitation, and organ support. Reserve antibiotics for proven infection. Delay intervention until walled‑off necrosis (~4 weeks) when feasible; employ a step‑up approach starting with percutaneous or endoscopic drainage and escalating to minimally invasive necrosectomy if needed.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions when predefined failure criteria are met. Define ICU, step‑down, and ward disposition triggers explicitly, and arrange specialty consultation early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitating factors
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Anemia/leukocytosis | Context‑specific | Trend response |
| BMP | Electrolytes/renal | Derangements common | Renal dosing/monitoring |
| Condition‑specific imaging | Per topic | Diagnostic hallmark | Do not delay with red flags |
| Contrast CT (72–96 h) | Assess necrosis/collections | Non‑enhancing areas | Repeat to guide intervention |
| CRP/procalcitonin | Inflammation/infection | Elevated when infected | Guide antibiotics |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Piperacillin–tazobactam or Carbapenem | β‑lactam/carbapenem | Hours | Infected necrosis coverage | Culture‑directed; stewardship |
| Enteral feeding (nasojejunal) | Physiologic support | Hours | Reduces infectious complications | Avoid TPN if possible |
| Analgesia (opioid‑sparing) | Multimodal | Immediate | Pain control | Avoid ileus |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy
Patient Education / Counseling
- Explain red flags, adherence, and the follow‑up plan; provide written instructions.
References
- See bibliography — Link