Acute Pancreatitis

Meet the patient

A 58-year-old man arrives at 3am with severe epigastric pain boring through to his back, vomiting that brings no relief, and a pulse of 118. He drinks heavily and his lipase is eight times the upper limit of normal, and the ultrasound shows a gallstone.^[2]

The two questions that decide his course are how severe this will become, and whether the old reflexes — wide-open fluids, nil by mouth, prophylactic antibiotics — will be resisted. Hold those two questions and the modern bundle below slots into place.^[1]

Hasibeder: eighty per cent of episodes are related either to gallstones or to alcohol. Moody: gallstones account for 30 to 50 per cent of presentations. A UK series (Davidson, 391 episodes) found gallstones in 56 per cent and alcohol in 16 per cent; Hu notes that the mix varies by region. Overall mortality is approximately 2 per cent, rising to approximately 30 per cent when persistent organ failure is present. The single most important paradigm shift in the last decade is the move away from uncontrolled aggressive fluid resuscitation (WATERFALL showed harm) and the abandonment of prolonged bowel rest in favour of early enteral feeding. ^{[9][8][10][14][3][2]}

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References20ShowHide

1. [1]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
2. [2]Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis Am J Gastroenterol, 2024.PMID 38857482
3. [3]de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis N Engl J Med, 2022.PMID 36103415
4. [4]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
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8. [8]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
9. [9]Hasibeder WR, Torgersen C, Rieger M Critical care of the patient with acute pancreatitis Anaesth Intensive Care, 2009.PMID 19400483
10. [10]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
11. [11]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
12. [12]Lee HW, Moon SH, Kim MH Relapse rate and predictors of relapse in a large single center cohort of type 1 autoimmune pancreatitis: long-term follow-up results after steroid therapy with short-duration maintenance treatment J Gastroenterol, 2018.PMID 29362937
13. [13]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
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19. [19]Szatmary P, Grammatikopoulos T, Cai W, et al. Acute Pancreatitis: Diagnosis and Treatment Drugs, 2022.PMID 36074322
20. [20]Working Group IAP/APA Acute Pancreatitis Guidelines IAP/APA evidence-based guidelines for the management of acute pancreatitis Pancreatology, 2013.PMID 24054878