EM · Acute pancreatitis
Acute pancreatitis
Also known as Acute pancreatitis · Severe acute pancreatitis · Gallstone pancreatitis · Alcoholic pancreatitis
Acute pancreatitis — severe epigastric pain radiating straight through to the back with vomiting, lipase three times the upper limit of normal, gallstones and alcohol as the dominant causes, Revised Atlanta severity, BISAP at the door, WATERFALL moderate goal-directed lactated Ringer's, early enteral feeding, antibiotics reserved for infected necrosis, and ERCP for cholangitis. ACEM-primary, globally tagged.
Checked against its sources on 4 Sept 2026
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- Severe epigastric pain radiating to the back with a lipase 3 times the upper limit of normal is acute pancreatitis until proven otherwise — but the lethal mimics (perforated ulcer, mesenteric ischaemia, inferior MI) must be excluded first
- Persistent organ failure beyond 48 hours defines severe pancreatitis — these patients need intensive care, not the ward
- Prophylactic antibiotics do NOT prevent infected pancreatic necrosis and are not given — reserve antibiotics for proven or strongly suspected infected necrosis
- Fever and sepsis in the second week with necrosis on CT suggests infected necrosis — the indication for antibiotics and a delayed step-up drainage approach
- WATERFALL: aggressive 20 mL/kg then 3 mL/kg/h caused fluid overload without outcome benefit — do not pour
Meet the patient
A 58-year-old obese woman presents with eight hours of severe epigastric pain radiating straight through to the back, repeated vomiting and jaundice. She has known gallstones. She is in pain and distressed: temperature 38.4, heart rate 124, blood pressure 92 over 58, respiratory rate 28, SpO₂ 92 percent on room air. Lipase 1240 (ULN 60), bilirubin 68, calcium 2.05. The ABG shows a PaO₂ of 7.6 kPa.[1]
The two questions that decide her next hour are the two that decide every pancreatitis: is this organ failure at the front door? (hypoxaemia and shock already answer) and can I resuscitate her without over-doing it? (WATERFALL moderate fluids answer). Hold those two and the whole management slots into place.[4][2]
References18ShowHide
- [1]Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis Am J Gastroenterol, 2013.PMID 23896955
- [2]Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus Gut, 2013.PMID 23100216
- [3]Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis Pancreatology, 2013.PMID 24054878
- [4]de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis N Engl J Med, 2022.PMID 36103415
- [5]Besselink MG, van Santvoort HC, Buskens E, et al. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial Lancet, 2008.PMID 18279948
- [6]van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis N Engl J Med, 2010.PMID 20410514
- [7]Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study Gut, 2008.PMID 18519429
- [8]Pongprasobchai S, Jianjaroonwong V, Charatcharoenwitthaya P, et al. Erythrocyte sedimentation rate and C-reactive protein for the prediction of severity of acute pancreatitis Pancreas, 2010.PMID 20531240
- [9]Szatmary P, Grammatikopoulos T, Cai W, et al. Acute pancreatitis: diagnosis and treatment Drugs, 2022.PMID 36074322
- [10]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis Am J Gastroenterol, 2024.PMID 38857482
- [11]Hasibeder WR, Torgersen C, Rieger M. Critical care of the patient with acute pancreatitis Anaesth Intensive Care, 2009.PMID 19400483
- [12]Davidson BR, Neoptolemos JP, Leese T. Biochemical prediction of gallstones in acute pancreatitis: a prospective study of three systems Br J Surg, 1988.PMID 2450614
- [13]Moody N, Adiamah A, Yanni F, et al. Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis Br J Surg, 2019.PMID 31268184
- [14]Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer's solution reduces systemic inflammation compared with saline in patients with acute pancreatitis Clin Gastroenterol Hepatol, 2011.PMID 21645639
- [15]Poropat G, Goričanec K, Lacković A, et al. Systematic Review with Trial Sequential Analysis of Prophylactic Antibiotics for Acute Pancreatitis Antibiotics (Basel), 2022.PMID 36139970
- [16]Papachristou GI, Muddana V, Yadav D, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis Am J Gastroenterol, 2010.PMID 19861954
- [17]Ranson JH. The timing of biliary surgery in acute pancreatitis Ann Surg, 1979.PMID 443917
- [18]Hu Q, Hu Y, Tan C. Acute pancreatitis: mechanisms and therapeutic approaches Signal Transduct Target Ther, 2026.PMID 41530118