In an adult presenting with acute epigastric pain radiating to the back, nausea/vomiting, and serum lipase or amylase greater than three times the upper limit of normal, what is the comprehensive approach to diagnosis, severity assessment, initial management, monitoring, complication handling, and discharge planning for acute pancreatitis?

Acute Pancreatitis: Comprehensive Clinical Management

Diagnosis

Diagnose acute pancreatitis when at least two of three criteria are present: (1) abdominal pain consistent with pancreatitis (acute epigastric pain radiating to the back), (2) serum lipase and/or amylase greater than three times the upper limit of normal, and (3) characteristic findings on abdominal imaging. 1

Key Diagnostic Points

• Lipase is preferred over amylase when available due to superior diagnostic accuracy 1
• Contrast-enhanced CT or MRI should be reserved for patients with diagnostic uncertainty or those who fail to improve clinically—routine imaging at presentation is unnecessary 2
• Abdominal ultrasound should be performed within the first 48 hours to identify gallstones as the etiology 1, 2
• Chest radiograph is indicated to identify pleural effusions, pneumonic consolidation, or ARDS 3

Clinical Presentation Red Flags

• Persistent back pain indicates retroperitoneal infiltration and signals more severe disease 3
• Prolonged ileus and abdominal distension indicate severity 3
• Anorexia and malaise frequently accompany the pain 3
• Common pitfall: Not all severe cases present dramatically—some have subtle findings that progress rapidly 3

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Severity Assessment and Classification

All patients must be assessed for severity within 48 hours of admission using validated scoring systems, as clinical assessment alone misclassifies approximately 50% of patients. 1

Three-Tier Severity Classification (Revised Atlanta 2012)

1. Mild (80% of cases, <5% mortality): No organ failure, no local or systemic complications; resolves within first week 4, 1

2. Moderately Severe: Transient organ failure (<48 hours) and/or local complications or exacerbation of comorbidities 1

3. Severe (20% of cases, 95% of deaths): Persistent organ failure (>48 hours) affecting cardiovascular, respiratory, and/or renal systems 4, 1

Severity Scoring Systems

APACHE II score ≥8-9 indicates severe disease and should be used as the primary scoring system 1

• Can be applied immediately upon admission 1
• Should be repeated daily in severe cases to monitor for progression or sepsis 1
• Provides 70-80% accuracy 1

Glasgow score ≥3 indicates severe disease 1

• Validated in UK populations 1
• Requires 48 hours to complete 1
• Three or more positive criteria constitute severe disease 1

C-reactive protein >150 mg/L indicates severity 1

• Peak >210 mg/L in first 4 days or >120 mg/L at end of first week indicates severity with ~80% accuracy 1
• Combining CRP with Glasgow criteria improves prognostication 1
• Not valid until 48-72 hours after pain onset 5

Body mass index >30 can be used as an additional severity marker 1

Critical Timing Considerations

• Patients must be observed for at least 48 hours to differentiate transient from persistent organ failure 1
• Persistent organ failure is the key determinant of mortality 1
• Persistent SIRS increases mortality to 25.4% compared with 0.7% without SIRS 1

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Etiological Investigation

The etiology should be determined in 75-80% of cases; no more than 20-25% should remain "idiopathic." 4

Early Assessment (Within 48 Hours)

• Abdominal ultrasound for gallstones (repeat if initially negative) 4, 1
• Early increase in serum aminotransferases or bilirubin suggests gallstone etiology 4
• Serum triglycerides, calcium, full blood count, renal and liver function tests, glucose 6

Late Assessment (After Acute Phase)

• Blood lipid and calcium concentrations if etiology not established 4
• ERCP indications: presence of jaundice, dilated common duct, recurrent attacks, or concurrent acute cholangitis 4
• ERCP with sphincterotomy within 24 hours for patients with acute cholangitis 2
• MRCP or endoscopic ultrasound to detect occult common bile duct stones in unexplained cases 1
• CT scan (particularly in elderly) to exclude pancreatic tumor if etiology remains obscure 4
• Bile sampling for microlithiasis in patients with repeated attacks and no identified cause 4

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Initial Management by Severity

Mild Acute Pancreatitis (General Ward Management)

Patients with mild disease can be managed on general wards with basic monitoring of temperature, pulse, blood pressure, and urine output. 4

Fluid Resuscitation

• Aggressive intravenous hydration should be provided to all patients unless cardiovascular or renal comorbidities preclude it 2
• Early aggressive IV hydration is most beneficial within the first 12-24 hours and may have little benefit beyond 2
• All patients require peripheral IV access for fluids 4

Nutrition

• Oral feedings can be started immediately if there is no nausea and vomiting 2
• Nasogastric tube may be needed but few warrant indwelling urinary catheter 4

Antibiotics

• Antibiotics should NOT be administered routinely as there is no evidence they affect outcome or reduce septic complications in mild cases 4
• Antibiotics are warranted only when specific infections occur (chest, urine, bile, or cannula-related) 4

Imaging

• Routine CT scanning is unnecessary unless there are clinical or other signs of deterioration 4

Treatments NOT Recommended

• Aprotinin, glucagon, somatostatin, fresh frozen plasma, and peritoneal lavage have no proven value and cannot be recommended 4

Definitive Management

• For gallstone pancreatitis, cholecystectomy should be performed within 2 weeks and no later than 4 weeks after onset 1

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Severe Acute Pancreatitis (ICU/HDU Management)

Patients with persistent organ failure must be admitted to an intensive care unit or high-dependency unit whenever possible. 4, 1

Monitoring and Access

• Minimum requirements: peripheral venous access, central venous line (for fluid administration and CVP monitoring), urinary catheter, and nasogastric tube 4
• Strict asepsis must be observed in placement and care of invasive monitoring equipment, as these may serve as sources of subsequent sepsis 4
• Swan-Ganz catheter required when cardiocirculatory compromise exists or initial resuscitation fails 4
• Regular arterial blood gas analysis is essential 4

Nursing Assessment

• Hourly monitoring minimum: pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 4
• Accurate charting with cumulative fluid balance calculations 4

Antibiotics in Severe Disease

• Prophylactic antibiotics are NOT routinely recommended for severe AP with sterile necrosis 2
• Intravenous cefuroxime is a reasonable balance between efficacy and cost when prophylaxis is considered 4
• In patients with infected necrosis, antibiotics that penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality 2

Nutrition

• Enteral nutrition is recommended to prevent infectious complications 2
• Parenteral nutrition should be avoided 2

Imaging

• Contrast-enhanced CT should be performed 72-96 hours after symptom onset for all patients with severe disease to assess pancreatic necrosis 1
• Performing CT before 72 hours may underestimate the true extent of necrosis and should be avoided 1

Multidisciplinary Approach

• Full resuscitation and multidisciplinary approach reduces early deaths from circulatory, respiratory, and renal failure 4
• Referral to specialist tertiary center with interventional radiology, endoscopy, and surgical expertise is advised 1

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Complications and Their Management

Local Complications Timeline and Definitions

Complication	Timing	Key Features	Citation
Acute peripancreatic fluid collection	Early phase (first week)	Fluid-filled collection adjacent to pancreas, lacking defined wall	[1]
Acute necrotic collection	Within first 4 weeks	Mixed fluid and necrotic debris, no mature wall	[1]
Pseudocyst	≥4 weeks from onset	Encapsulated collection of pancreatic juice bounded by fibrous/granulation tissue	[1]
Walled-off necrosis (WON)	≥4 weeks	Encapsulated necrotic collection with well-defined, enhancing inflammatory wall	[1]

Infection and Mortality Risk

• Infected necrosis with persistent organ failure has the highest mortality (up to 35.2%) 1
• Sterile necrosis with organ failure: ~19.8% mortality 1
• Infected necrosis without organ failure: ~1.4% mortality 1
• In the late phase (after first week), infection of necrotic tissue becomes the dominant concern 1

Intervention Principles

• Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do NOT warrant intervention regardless of size, location, or extension 2
• Asymptomatic fluid collections should not be drained—unnecessary percutaneous procedures risk introducing infection 3
• In stable patients with infected necrosis, drainage should be delayed preferably for 4 weeks to allow wall development 2
• Surgical, radiologic, and/or endoscopic drainage options should be considered 2

Signs of Deterioration Requiring Immediate Action

• Onset of cardiorespiratory failure indicates septic complications 3
• Development of renal failure signals severe disease 3
• Sudden high fever warrants immediate investigation for infection (low-grade fever alone does not necessarily indicate deterioration) 3
• Increasing leucocyte and platelet counts suggest possible sepsis 3
• Deranged clotting parameters indicate severe disease 3
• Severe and rapid weight loss suggest complications 3
• Failure to thrive with hypermetabolism and catabolic state suggests complication development 3

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Prognostic Targets

Overall mortality should be lower than 10%, and less than 30% in severe cases. 1

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Post-ERCP Pancreatitis Prevention

Pancreatic duct stents and/or post-procedure rectal NSAID suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients 2

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Critical Clinical Pitfalls to Avoid

• Never rely on clinical assessment alone—it misclassifies ~50% of patients 1
• Do not transfer patients with only transient organ failure prematurely to tertiary centers or ICU; persistent failure must be documented for >48 hours 1
• Avoid contrast-enhanced CT before 72 hours—it underestimates necrosis extent 1
• Do not routinely use antibiotics in mild or severe disease with sterile necrosis 4, 2
• Do not use parenteral nutrition when enteral feeding is possible 2
• Do not intervene on asymptomatic collections—this introduces infection risk 3, 2