RotationRx · Drugs · Scores · Protocols · Diagnoses · Specialties

← Diagnosis and Management Guides

Acute Pancreatitis

Key considerations: Necrotizing pancreatitis, Infected necrosis, Pancreatic abscess

Cannot miss

  • Necrotizing pancreatitis
  • Infected necrosis
  • Pancreatic abscess
  • Hemorrhagic pancreatitis
  • Aortic dissection mimicking

Likely diagnoses

  • Gallstone pancreatitis
  • Alcoholic pancreatitis
  • Hypertriglyceridemia-induced
  • Drug-induced
  • Post-ERCP pancreatitis

Red flags

  • Ranson criteria >=3
  • Organ failure at presentation
  • SIRS criteria
  • Grey Turner sign (flank bruising)
  • Cullen sign (periumbilical bruising)
  • Failure to improve at 48-72 hours

Workup

  • history: Alcohol use, gallstone history, medications, hypertriglyceridemia, recent ERCP, family history; exam: Epigastric tenderness, guarding, Grey Turner/Cullen signs, fever, tachycardia; labs: Lipase (>3x ULN diagnostic); CBC, BMP, LFTs (gallstone etiology if elevated), triglycerides, calcium, alcohol level; imaging: CT abdomen with contrast if diagnosis unclear or not improving at 48-72 hours (not needed initially); RUQ ultrasound for gallstone etiology; bedside: Serial abdominal exams, SIRS criteria assessment

Management

  • immediate: Aggressive IV fluid resuscitation (LR preferred, 250-500 mL/hr initially); NPO until pain controlled and nausea resolved; Analgesia (IV opioids); general: Early enteral nutrition within 24-48 hours (superior to NPO); ERCP if gallstone pancreatitis with cholangitis; Antibiotics ONLY if infected necrosis confirmed — NOT prophylactically; Cholecystectomy during same admission for gallstone pancreatitis if mild

Disposition

  • admit: All acute pancreatitis — ICU if severe (organ failure, Ranson >=3); discharge: Mild (Ranson 0-2) if tolerating oral intake and pain controlled; consults: GI for ERCP if gallstone with cholangitis, surgery for cholecystectomy/necrosectomy

Clinical pearls

  • Prophylactic antibiotics are NOT indicated in acute pancreatitis even with necrosis — only treat if infected necrosis confirmed
  • LR is preferred over NS for resuscitation — associated with decreased SIRS and CRP
  • Early enteral nutrition (within 24-48 hours) is superior to prolonged NPO — reduces infection and mortality

Source and review

  • ACG Acute Pancreatitis Guidelines 2024. Last reviewed: 2024-11-01