Skip to content

Acute Pancreatitis

Alex Wiles


  • Common causes: Gallstones (40%), EtOH (30%)
  • Other causes: post-ERCP, pancreatic cancer/obstruction, blunt abdominal trauma, hypertriglyceridemia (TG >1000), hypercalcemia, drugs (thiazides, protease inhibitors, azathioprine, 6MP), mumps, Coxsackie, vasculitis, pregnancy, genetic (PRSS1, SPINK1, CFTR), autoimmune (IgG4), scorpion venom
  • Several scoring systems:
    • BISAP (BUN >25, Impaired mental status, SIRS, Age >60, Pleural effusion)
      • 0–2 Mortality <2%; 3-5 Mortality >15%
    • APACHE II (MD Calc, several factors)
      • 0–8 Mortality <4%; > 8 Mortality 11–18%


  • Must have 2 out of the three:
    • Pain characteristic of pancreatitis (sharp, epigastric, radiating to back)
    • Imaging characteristic of pancreatitis (US, CT, MRI)
    • Enzymes (lipase or amylase) >3x ULN (use lipase, much more specific)
    • *If pain is characteristic and lipase > 3x ULN, no need for CT A/P
  • Grading Severity:
    • Mild: no organ failure or systemic complications
    • Moderate: transient organ failure (<48 hours)
    • Severe: persistent organ failure (>48 hours)


  • Lipase, CBC, CMP, lipid panel, lactate, direct bilirubin
  • Obtain RUQ U/S for all pts, evaluates for gallstones
  • CT A/P w/ IV contrast if indicated
    • Reserved for patients not improving at 48-72 hour to assess for complications
    • If performed at onset, underestimates severity (necrosis takes 72 hours from onset)


  • Fluids, Fluids, Fluids:
    • First 12-24 hrs: IVF at 200 to 500 cc/hr, or 5-10 cc/kg / hr (2.5 –

      4 L within first 24 hrs)

    • Follow HCT and BUN as markers for successful fluid resuscitation
    • Aggressive IVF in first 24 hours reduces both morbidity and mortality
    • Persistent hemoconcentration at 24 hr is associated with necrotizing pancreatitis
  • Pain Control:
    • Common starting narcotic regimen is oxycodone 10 mg q6h PRN and hydromorphone 0.5 mg q4h for breakthrough
  • Nutrition:
    • NPO but start PO diet as soon as patient can tolerate (even within 24 hours)
    • Clear liquid diet or mechanical soft and advance as tolerated
    • Low fat diet (Fatty acids → CCK → trypsinogen to trypsin)
    • If NPO > 72 hours, attempt PO and if fail, place Dobhoff for enteral nutrition at latest by day five… outcomes with NG/NJ >>> TPN
  • Antibiotics:
    • Fever, leukocytosis common, not an indication for ABX as the necrosis is sterile
    • Infection of the necrosis should be suspected with failure to improve 7 days after onset
    • Cefepime + Flagyl or carbapenem
  • EUS or IR guided drain for aspirate: can be done on immature collections for diagnostic purposes but typically only done if collection is walled-off—at least 4 weeks
  • Endoscopic Intervention (cystogastrostomy) has emerged as first-line therapy for symptomatic pseudocysts or walled-off pancreatic necrosis , with step-up therapy to video assisted retroperitoneal debridement (VARD) or surgery when needed

Additional Information

  • If choledocholithiasis on Imaging urgent ERCP for patients with cholangitis or obstructive jaundice, otherwise elective ERCP
  • If Intermediate probability for choledocholithiasis MRCP or EUS or (for patients requiring cholecystectomy Intraoperative cholangiogram
  • If biliary sludge but no stones on U/S, still consider cholecystectomy (likely microlithiasis)
  • Complications:
    • ARDS, abdominal compartment syndrome, AKI, DIC
    • < 4 weeks after pancreatitis: Peripancreatic fluid collection, acute necrotic collection
    • 6 weeks after pancreatitis: Pancreatic pseudocyst, walled-off necrosis (WON)

  • Most fluid collections should be followed over time as acute collections can resolve and are unable to be sampled safely with EUS
  • Gallstone pancreatitis:
    • All pts should have cholecystectomy once recovered (recurrence is 25-30%) with EGS
    • Performed during initial admission in cases of mild acute pancreatitis