Acute Pancreatitis

Key considerations: Necrotizing pancreatitis, Infected pancreatic necrosis, Organ failure

Cannot miss

history: Epigastric pain radiating to back, alcohol use, gallstone history, medications, hypertriglyceridemia; exam: Epigastric tenderness, guarding, decreased bowel sounds; labs: Lipase (>3x ULN = diagnostic), CBC, BMP, LFTs (ALT >150 suggests gallstone), triglycerides, calcium, lactate; imaging: CT with contrast only if diagnostic uncertainty or failure to improve at 48-72hr; RUQ US to evaluate for gallstones/CBD dilation; bedside: BISAP score at admission

immediate: Aggressive IV fluid resuscitation (LR preferred, 1.5mL/kg/hr initially); Pain management (IV opioids, ketorolac); NPO initially, then advance diet as tolerated; general: Early oral feeding when tolerated (within 24hr if possible) — do NOT wait for lipase to normalize; Gallstone pancreatitis: cholecystectomy during same admission; No prophylactic antibiotics for sterile necrosis; ERCP only if concurrent cholangitis or persistent biliary obstruction

admit: All acute pancreatitis; discharge: After pain controlled, tolerating PO, etiology addressed; consults: GI for ERCP if needed, surgery for cholecystectomy

Early oral feeding improves outcomes — the old "bowel rest" approach is outdated
Prophylactic antibiotics do NOT prevent infected necrosis — ONLY use antibiotics if infection documented
ALT >150 has 95% PPV for gallstone pancreatitis