What is the recommended approach for severity assessment and management of acute pancreatitis in a patient with a history of gallstones, hypertriglyceridemia, or certain medications?

Severity Assessment of Acute Pancreatitis

Severity stratification should be performed in all patients within 48 hours using the APACHE II scoring system (cutoff ≥8) combined with C-reactive protein measurement (>150 mg/L at 48 hours), and patients with predicted severe disease, persistent organ failure, or APACHE II >8 require immediate ICU/intermediate care triage and contrast-enhanced CT after 72 hours. 1, 2

Initial Clinical Assessment and Risk Stratification

Persistent or progressive organ failure is the single most important predictor of mortality and defines severe disease, regardless of other factors. 1 Organ failure that resolves within 48 hours should not be classified as severe acute pancreatitis. 1

Key Severity Markers Within First 24-48 Hours:

• APACHE II score ≥8 is the preferred multifactor scoring system for predicting severe disease 1, 2
• Glasgow score ≥3 (alternative validated system in UK populations) 1
• C-reactive protein >150 mg/L at 48 hours after symptom onset 1, 2
• Clinical impression of severity and obesity are independent predictors 1
• Hematocrit >44% and blood urea nitrogen >20 mg/dL are additional severity markers 2

Critical pitfall: Do not rely on a single assessment—severity can evolve rapidly, so reassess at least every 48 hours, as mild disease at presentation can progress to severe. 3

Etiological Assessment (Mandatory at Admission)

The etiology must be established in at least 75-80% of cases—accepting "idiopathic" pancreatitis without thorough investigation is unacceptable. 1, 2, 4

Required Initial Laboratory Tests:

• Serum lipase or amylase (lipase preferred for greater specificity) 1, 2
• Liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) to identify gallstone etiology 1, 2, 4
• Triglyceride level (if not obtainable at admission, measure fasting levels after recovery) 1
• Serum calcium level to identify hypercalcemia 1, 4

Required Initial Imaging:

• Abdominal ultrasonography at admission to screen for cholelithiasis/choledocholithiasis 1, 2, 4
• If initial ultrasound inadequate, repeat after recovery or use endoscopic ultrasound (EUS) 1

Detailed History Must Include:

• Alcohol intake quantified in units per week 1, 2, 4
• History of hypertriglyceridemia or hypercalcemia 1
• Complete medication history (prescription and non-prescription drugs) 1
• Family history of pancreatic disease 1, 4
• History of trauma 1, 4

Imaging Strategy for Severity Assessment

Contrast-enhanced CT should be performed after 72-96 hours (not before) in patients with predicted severe disease (APACHE II >8) or evidence of organ failure during initial 72 hours. 1, 2, 4

Critical pitfall: Early CT (within 72 hours) is unreliable for assessing pancreatic necrosis and should be avoided unless diagnostic uncertainty exists. 1, 4 Performing CT too early will underestimate the extent of necrosis and provide false reassurance.

CT Indications:

• APACHE II score >8 1
• Evidence of organ failure during initial 72 hours 1
• Persisting organ failure, signs of sepsis, or clinical deterioration at 6-10 days 1
• Diagnostic uncertainty (when pancreatitis diagnosis itself is unclear) 1, 4

Triage and Monitoring Decisions

Patients requiring ICU/intermediate care unit admission: 1, 2

• Predicted severe disease (APACHE II ≥8 or Glasgow ≥3)
• Actual severe disease with organ failure
• Persistent organ failure (lasting >48 hours)
• Severe comorbid medical conditions

Ongoing monitoring in severe cases: Use daily APACHE II scoring to track disease progression, recovery, or onset of sepsis. 1

Additional Investigations for Unexplained Pancreatitis

• Age >40 years with unexplained pancreatitis: Perform CT or EUS to exclude pancreatic malignancy 1, 4
• Recurrent unexplained pancreatitis: EUS is preferred as initial test over ERCP 1, 4
• Single episode in patients <40 years: Extensive invasive evaluation not recommended 1, 4
• Consider MRCP or EUS to screen for occult common bile duct stones when etiology remains unclear 1

Management of Gallstone Pancreatitis

Urgent ERCP (within 24 hours) is required for patients with gallstone pancreatitis AND concomitant cholangitis. 1

Early ERCP (within 72 hours) should be performed in those with high suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated common bile duct, or jaundice). 1

All patients with biliary pancreatitis should undergo definitive gallstone management during the same hospital admission or within 2 weeks to prevent recurrence. 1