Acute presentations and emergencies

Pancreatitis

Overview and approach

Acute pancreatitis is diagnosed using at least two of typical pain, pancreatic enzymes above the diagnostic threshold, and compatible imaging.

  • Enzyme threshold: lipase (or amylase) over three times the upper limit of normal. Common causes: gallstones, alcohol, hypertriglyceridaemia, post-ERCP, drugs, hypercalcaemia, trauma.
  • Revised Atlanta severity: mild = no organ failure or local complication; moderately severe = transient organ failure or local complications; severe = persistent organ failure over 48 hours (1).
Assessment and clinical features

Epigastric pain radiating to the back, vomiting and systemic illness; assess alcohol, gallstones, medicines and organ dysfunction.

  • Look for dehydration, tachycardia, hypoxia, jaundice (stone or cholangitis), Cullen and Grey Turner signs (late, severe).
Differentials and investigations

Lipase, FBC, renal/electrolytes, LFTs, glucose and calcium; ultrasound for gallstones. CT is selective for uncertainty, deterioration or complications rather than automatic early scanning.

  • Also triglycerides, CRP, ABG if unwell. Differentials: perforated ulcer, mesenteric ischaemia, cholecystitis, MI, aortic dissection.
Management and follow-up

Analgesia, carefully reassessed IV fluids and early enteral intake when tolerated; treat the cause. No routine prophylactic antibiotics for sterile pancreatitis.

  • Fluids: lactated Ringer's rather than saline with moderate goal-directed resuscitation (IAP 2025: 1.5 mL/kg/h, 10 mL/kg bolus only if hypovolaemic); reassess often (2).
  • Feeding: oral low-fat diet as soon as tolerated, usually within 24-48 hours; avoid routine nil by mouth (3)(4).
  • Antibiotics: no prophylaxis; treat proven extrapancreatic infection or suspected infected necrosis (2).
  • Cause: gallstone pancreatitis needs cholecystectomy planning (same admission for mild disease per local protocol); ERCP for cholangitis or persistent obstruction. See Gallstone disease and Cholangitis pages.
Red flags and clinical pearls

Shock, hypoxia, oliguria, cholangitis or persistent organ failure needs urgent senior/critical-care input. Avoid indiscriminate large-volume fluids.

  • Stop alcohol; offer alcohol brief intervention. Screen for withdrawal.
References
  1. Diagnosis and Management of Acute Pancreatitis (Gastroenterology)
  2. IAP Revised Guidelines on Acute Pancreatitis 2025
  3. ACG Guidelines: Management of Acute Pancreatitis (PMC)
  4. IAP 2025 revised guidelines (Erasmus MC PDF)

Last updated from Sen’s notes on 9 October 2026.