What is the appropriate assessment and management for a patient with suspected acute pancreatitis?

Assessment and Management of Acute Pancreatitis

The diagnosis and management of acute pancreatitis requires prompt laboratory testing with lipase (preferred over amylase), appropriate fluid resuscitation with Lactated Ringer's solution, and risk stratification within the first 48 hours of admission to guide treatment decisions. 1

Diagnostic Approach

Initial Diagnosis

• Diagnosis requires at least 2 of 3 criteria:
  • Characteristic abdominal pain (epigastric, radiating to back)
  • Serum lipase or amylase ≥3 times upper limit of normal (lipase preferred) 2
  • Characteristic findings on imaging 3

Laboratory Assessment

• Lipase is the preferred diagnostic enzyme (higher sensitivity and specificity than amylase) 2
• Additional tests:
  • Complete blood count
  • Comprehensive metabolic panel (liver function tests)
  • Triglycerides
  • C-reactive protein (CRP >150 mg/L at 48 hours predicts severe disease) 2

Imaging

• Initial ultrasound to evaluate for gallstones
• Contrast-enhanced CT scan should be performed:
  • When diagnosis is uncertain
  • For patients with severe disease or clinical deterioration
  • Optimally between days 3-10 of admission 1
  • To assess for complications (necrosis, collections) 2

Severity Assessment

Risk Stratification

• Perform within first 24-48 hours using:
  • Clinical impression
  • APACHE II score
  • Glasgow score (≥3 indicates severe disease)
  • Presence of organ failure
  • CRP >150 mg/L at 48 hours 2
  • CT severity index 3

Red Flags for Severe Disease

• Persistent organ failure >48 hours
• Obesity
• Signs of sepsis
• Clinical deterioration 6-10 days after admission 2

Management Protocol

Initial Resuscitation

• Moderate fluid resuscitation with Lactated Ringer's solution is preferred over aggressive hydration or normal saline:
  • For hypovolemic patients: 10 mL/kg bolus
  • For normovolemic patients: no bolus
  • Maintenance: 1.5 mL/kg/hour 4
• Avoid aggressive fluid resuscitation (20 mL/kg bolus followed by 3 mL/kg/hour) as it increases risk of fluid overload without improving outcomes 4
• Monitor response to fluids within first 24-48 hours 1

Pain Management

• First-line: Opioid analgesics (do not increase risk of complications) 1
• Adjuncts:
  • Paracetamol (acetaminophen)
  • NSAIDs/COX-2 inhibitors
  • Consider thoracic epidural for severe cases 1

Nutritional Support

• Mild pancreatitis: Early oral feeding with low-fat diet when pain improves and inflammatory markers decrease
• Severe pancreatitis: Enteral nutrition preferred over parenteral nutrition 1
  • Nasogastric feeding is effective in ~80% of cases 2
  • Consider pancreatic enzyme supplements to maintain weight 1

Management of Gallstone Pancreatitis

• Urgent ERCP with sphincterotomy indicated for:
  • Cholangitis
  • Jaundice
  • Dilated common bile duct
  • Severe predicted or actual pancreatitis 2
• Perform ERCP within 72 hours of onset (within 24 hours for sepsis/septic shock) 1
• Laparoscopic cholecystectomy:
  • For mild gallstone pancreatitis: within 2-4 weeks, preferably during same admission
  • For severe pancreatitis: delay until inflammation resolves 1

Antibiotic Use

• Not routinely recommended for prophylaxis
• Consider antibiotics for:
  • Infected pancreatic necrosis (confirmed by fine-needle aspiration)
  • Cholangitis
  • If used, limit to maximum 14 days 2

Management of Complications

Local Complications

• For pancreatic necrosis or collections:
  • Perform contrast-enhanced CT to assess extent and characteristics
  • Avoid early intervention (wait for walled-off necrosis, typically >4 weeks)
  • Consider drainage for infected collections 1

Monitoring for Deterioration

• Patients with severe pancreatitis require:
  • High-dependency or intensive care monitoring
  • Serial clinical assessments
  • Repeat inflammatory markers
  • Follow-up imaging if clinical deterioration occurs 1

Common Pitfalls to Avoid

• Overaggressive fluid resuscitation increases risk of fluid overload (20.5% vs. 6.3%) without improving outcomes 4
• Delayed diagnosis beyond 48 hours increases morbidity 2
• Unnecessary use of antibiotics for sterile necrosis
• Premature intervention for pancreatic collections before adequate walling-off
• Parenteral nutrition when enteral feeding is possible increases complications 1
• Delayed ERCP in gallstone pancreatitis with cholangitis or biliary obstruction