PassFinals
Gastroenterology & Nutrition

Acute Pancreatitis

Acute pancreatitis is pancreatic inflammation with local and systemic inflammatory consequences; diagnose it clinically and biochemically, treat early with monitored supportive care and enteral nutrition, and prevent recurrence by addressing the cause.

In a nutshell

Acute pancreatitis is diagnosed by two of typical pain, pancreatic enzymes more than three times the upper limit of normal or characteristic imaging. Gallstones and alcohol are common causes. Treat with monitored supportive care and early enteral nutrition, do not give prophylactic antibiotics, and define severe disease by persistent organ failure rather than the enzyme level.

Classic presentation

Sudden severe epigastric pain radiating to the back with nausea or vomiting, often with gallstone risk or alcohol exposure. Assess immediately for hypovolaemia, hypoxia, kidney injury, jaundice and cholangitis.

Key points

  • The diagnosis requires two of three criteria; enzyme height does not grade severity.
  • Use ultrasound to look for a biliary cause and review alcohol, metabolic, medication, procedural, autoimmune and hereditary causes.
  • Do not routinely starve the person: resume oral intake as tolerated, and offer enteral nutrition within 72 hours in moderately severe or severe disease.
  • Do not give prophylactic antibiotics; reserve antimicrobials for infection such as cholangitis, infected necrosis or another proven source.
  • Severe acute pancreatitis means persistent organ failure beyond 48 hours; use serial physiology and organ-function assessment to identify it.
  • ERCP is for cholangitis or ongoing biliary obstruction, not uncomplicated gallstone pancreatitis.
  • Gallstone pancreatitis requires a plan for cholecystectomy when fit, with timing adapted to severity and collections.
  • Necrotic, infective, haemorrhagic or systemic complications need specialist pancreatic-centre advice.

First-line investigation

Serum lipase or amylase plus abdominal ultrasound for gallstones, with baseline organ-function tests and targeted imaging only when diagnosis is uncertain or complications are suspected.

Management

Resuscitate and identify organ failure

  • Give goal-directed crystalloid fluids, analgesia, antiemetics and oxygen if hypoxic, with repeated assessment of haemodynamics, urine output, breathing and renal function.1,3

Confirm the diagnosis and cause

  • Use two-of-three diagnostic criteria, ultrasound for gallstones and targeted review of alcohol, metabolic, drug, procedural, autoimmune and hereditary causes.1,4,3

Feed early and avoid prophylactic antibiotics

  • Do not routinely starve the person; use oral or enteral nutrition as tolerated and reserve antimicrobials for proven or strongly suspected infection.1,3

Prevent recurrence from the cause

  • Plan cholecystectomy when fit for gallstone pancreatitis, use urgent ERCP only for cholangitis or persistent biliary obstruction, and offer alcohol-support interventions where relevant.1,4,5,3

Escalate necrotising or systemic complications

  • Seek specialist pancreatic-centre advice for necrotic, infective, haemorrhagic or systemic complications; use endoscopic or percutaneous step-up management for infected necrosis when indicated.1,3

Safety-net and assess long-term consequences

  • Document the cause and recurrence plan, explain return symptoms, and arrange specialist follow-up for recurrent, idiopathic or complicated disease and later exocrine or endocrine dysfunction when indicated.1,3

Exam traps

  • A very high amylase or lipase does not mean severe pancreatitis; organ failure determines severity.
  • A normal late enzyme level does not exclude pancreatitis when typical pain and imaging support the diagnosis.
  • CT is not routinely needed in typical early disease; use it for uncertainty, deterioration or suspected complications and avoid premature staging.
  • ERCP is not routine in gallstone pancreatitis; urgent ERCP is for cholangitis or ongoing biliary obstruction.
  • Fever can be sterile inflammation; infected necrosis is a later complication requiring clinical, imaging and specialist assessment.
  • NPO is not routine: NICE recommends that food is not withheld without a clear reason.

Illustrations

Mechanism of pancreatic autodigestionDiagram showing premature intra-acinar activation of trypsinogen to trypsin, triggering activation of the full enzyme cascade and self-digestion of pancreatic tissue.PassFinals · original
Acute exudative pancreatitis on CTAxial CT showing an enlarged oedematous pancreas with surrounding inflammatory change and peripancreatic fluid.Hellerhoff, Wikimedia Commons · CC-BY-SA-3.0

Key sources

  1. NICE NG104: Pancreatitis (Current NICE recommendations for acute pancreatitis diagnosis, cause, antimicrobials, fluids, nutrition, complications, referral and follow-up; last updated 2020)Published 5 Sept 2018 | Updated 16 Dec 2020
  2. NICE NG29: Intravenous fluid therapy in adults in hospital (Assessment, prescription and monitoring principles for intravenous fluid resuscitation)
  3. Goodchild, Chouhan and Johnson: Practical guide to the management of acute pancreatitis (UK specialist review covering diagnosis, severity, imaging, supportive treatment, nutrition, gallstone management and necrotising disease)Published 1 May 2019
  4. NICE CG188: Gallstone disease — diagnosis and management (Bile-duct clearance, ERCP and laparoscopic cholecystectomy recommendations for gallstone disease)
  5. NICE QS104: Emergency ERCP within 24 hours (Quality standard for emergency ERCP when common bile-duct stones require urgent treatment, including cholangitis or non-responding acute pancreatitis)Published 3 Dec 2015

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.