Acute pancreatitis — severe gallstone disease with obstruction

Diagnosis. Acute pancreatitis (pain + lipase at least 3× ULN) with biliary features (jaundice, dilated CBD, stones) and organ failure at the front door (hypoxaemia, shock). Severity under Revised Atlanta 2012 is assigned by organ-failure duration: persistent organ failure (more than 48 hours) defines severe disease. Do not wait for a 48-hour score before escalating a shocked, hypoxaemic patient.^[2]

ABCDE resuscitation.

• Oxygen; large-bore IV access; urinary catheter; continuous monitoring; ICU/HDU referral given respiratory failure and shock.
• WATERFALL moderate lactated Ringer's: 10 mL/kg bolus because she is hypovolaemic, then 1.5 mL/kg/h, reassessed at 12, 24, 48 and 72 hours. Do not run a 10–20 mL/kg then 1.5–3 mL/kg/h hybrid of both arms. Aggressive 20 mL/kg then 3 mL/kg/h caused fluid overload 20.5 versus 6.3 percent (adjusted RR 2.85) without reducing moderately severe or severe pancreatitis.^[4]
• Analgesia with a titrated opioid; antiemesis. Do not quote unsourced morphine milligram doses.
• Early enteral feeding as nausea and vomiting settle; no prophylactic antibiotics (ACG 2013; Poropat mortality RR 0.85 NS, infected necrosis RR 0.81 NS).^[1][15]

Severity scoring. BISAP at the door (BUN over 25 mg/dL, impaired mentation, SIRS, age over 60, pleural effusion). Ranson/Glasgow complete at 48 hours (exam convention lists). CRP of 150 mg/L or greater at 36 hours predicted severe AP in Pongprasobchai.^[7][8]

Biliary pathway. ERCP within 24 hours if concurrent cholangitis (ACG 2013). ACG 2024: early ERCP if biliary pancreatitis is complicated by cholangitis. Do not quote an unsourced 24–72 hour obstruction-only clock. After resolution of mild disease, cholecystectomy on the index admission or within 2 weeks.^[1][10]

Exclude mimics. ECG/troponin (inferior MI), erect CXR (perforation), consider mesenteric ischaemia if pain out of proportion.^[1]