What is the recommended initial and ongoing management for a patient with suspected acute pancreatitis, including fluid resuscitation, analgesia, laboratory and imaging work‑up, severity assessment, nutrition, and indications for antibiotics, endoscopic retrograde cholangiopancreatography (ERCP), or drainage?

Management of Acute Pancreatitis

Initial Diagnosis and Laboratory Work-Up

All patients with suspected acute pancreatitis should have serum lipase or amylase measured at admission, with lipase preferred for diagnosis when available. 1

• Obtain serum triglyceride level, calcium level, and liver chemistries (bilirubin, AST, ALT, alkaline phosphatase) at admission to establish etiology 1
• Abdominal ultrasonography should be performed at admission to screen for cholelithiasis or choledocholithiasis 1
• Contrast-enhanced CT should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically within the first 72 hours, not for routine initial diagnosis 2, 3

Immediate Resuscitation and Supportive Care

Vigorous intravenous fluid resuscitation is the cornerstone of initial management and should be initiated immediately upon presentation. 1, 4

• Early aggressive hydration is most beneficial within the first 12-24 hours; goal-directed hydration with lactated Ringer's solution is preferred over aggressive normal saline 2, 3
• Assess hemodynamic status immediately and begin resuscitative measures as needed 2
• Provide supplemental oxygen as required and correct electrolyte and metabolic abnormalities 1
• Monitor hematocrit, BUN, creatinine, and continuous vital signs 4

Severity Assessment

Severity stratification must be performed within the first 48 hours using objective measures, as clinical examination alone is unreliable. 1

Initial Assessment (at presentation):

• Document any organ failure (cardiovascular, respiratory, renal compromise) 1
• Calculate APACHE II score 1
• Obtain chest x-ray 1
• Assess body mass index >30 as a risk factor 1

At 24 Hours:

• Repeat APACHE II score to capture worst values in first 24 hours 1
• Apply Glasgow score (though not complete until 48 hours) 1
• C-reactive protein >150 mg/L at 48 hours after disease onset is the preferred laboratory marker for severity 1

Admission Criteria:

• Patients with organ failure and/or systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or high dependency unit with full monitoring 4, 5, 2
• Mild acute pancreatitis (80% of cases) can be managed on general wards with as-needed opioids and close monitoring 4

Pain Management

For severe pain in acute pancreatitis, hydromorphone is preferred over morphine in non-intubated patients. 4, 5

Pain Management Algorithm:

• Mild pain: NSAIDs with or without acetaminophen (avoid NSAIDs if acute kidney injury present) 5
• Moderate pain: Weak opioids (codeine or tramadol) combined with non-opioid analgesics 5
• Severe pain: Morphine or hydromorphone as first-line opioid 4, 5

Critical Adjuncts:

• Laxatives must be routinely prescribed to prevent opioid-induced constipation 4, 5
• Metoclopramide for opioid-related nausea/vomiting 4, 5
• Consider Patient-Controlled Analgesia (PCA) or epidural analgesia for patients requiring high opioid doses 5
• For neuropathic pain components, consider gabapentin, pregabalin, nortriptyline, or duloxetine 5

No restrictions on pain medication are warranted; adequate pain control is the clinical priority. 5

Nutritional Support

In mild acute pancreatitis, oral feeding can be started immediately if there is no nausea and vomiting. 2

• Early enteral feeding is safe and beneficial when tolerated; the past emphasis on "gut rest" has been revised 4, 2, 3
• For patients likely to remain NPO for more than 7 days, nasojejunal tube feeding with elemental or semi-elemental formula is preferred over total parenteral nutrition 1, 2
• Total parenteral nutrition should be avoided and used only in those unable to tolerate enteral nutrition 1, 2

Antibiotic Use

Prophylactic antibiotics are not recommended for acute pancreatitis and do not decrease mortality or morbidity. 4, 2

Specific Indications for Antibiotics:

• Antibiotics are not required routinely for mild acute pancreatitis 1
• For severe acute pancreatitis with sterile necrosis, routine prophylactic antibiotics are not recommended 4, 2
• Antibiotics should only be given for confirmed infections (infected necrosis, pancreatic abscess, infected fluid collections) 4
• Procalcitonin is the most sensitive test for detecting pancreatic infection 4
• When infection is confirmed, use antibiotics that penetrate pancreatic necrosis (imipenem or cefuroxime have been studied) 1, 2
• Prophylactic antibiotics are indicated prior to invasive procedures such as ERCP and surgery 1

ERCP Indications and Timing

Urgent ERCP (within 24 hours) should be performed in patients with gallstone pancreatitis who have concomitant cholangitis. 1, 2

ERCP Algorithm:

• Cholangitis present: Urgent ERCP within 24 hours 1, 2
• High suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated CBD, jaundice): Early ERCP within 72 hours 1
• Predicted or actual severe gallstone pancreatitis without cholangitis or persistent stone: Controversial; practice varies by center 1
• No cholangitis and no evidence of persistent stone: ERCP not indicated 2, 3

Definitive Management:

• All patients with gallstone pancreatitis and gallbladder in situ should undergo cholecystectomy during the same hospital admission if possible, otherwise within 2-4 weeks after discharge 1, 6

Imaging for Severity Assessment and Complications

CT should be used selectively based on clinical features, not routinely in all patients. 1

CT Indications:

• Patients not improving clinically within 72 hours 1, 2
• Suspected complications (infected necrosis, abscess, pseudoaneurysm) 1
• In severe acute pancreatitis, dynamic contrast-enhanced CT should be repeated regularly, usually every two weeks, or more frequently if sepsis is suspected 1
• Use CT severity index (Balthazar score) when staging is required 1

Important Caveats:

• Early CT (before 4 days) may underestimate the final severity of necrosis 1
• Ultrasound is not helpful in established severe pancreatitis except for monitoring fluid collections 1
• Peripancreatic fluid collections occur in 30-50% of severe cases and resolve spontaneously in more than half; asymptomatic collections should not be drained 1, 4

Management of Necrosis and Drainage

Sterile necrosis does not usually require therapy. 1

Infected Necrosis Management:

• In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks (or more), to allow development of a wall around the necrosis 1, 4, 2
• Postponing definitive surgery for more than 4 weeks after disease onset lowers mortality risk 4
• A step-up strategy is advised: start with percutaneous or endoscopic drainage before proceeding to open surgical debridement 4
• Suspected intra-abdominal sepsis requires radiologically guided fine needle aspiration for microscopy and culture, though this procedure may introduce infection and should be performed cautiously by experienced radiologists 1

Fluid Collection Management:

• Indications for percutaneous aspiration: suspected infection and symptomatic collections causing pain or mechanical obstruction 1
• Asymptomatic fluid collections should not be drained regardless of size, location, or extension 2

Ongoing Monitoring and Reassessment

Daily reassessment for development of complications is necessary, including clinical, biochemical, and radiological evaluation. 4

Signs of Deterioration:

• Sudden high fever (moderate fever is common in necrotizing pancreatitis and does not necessarily indicate deterioration) 1
• Onset of cardiorespiratory or renal failure 1
• Increasing leucocyte and platelet counts, deranged clotting, rising APACHE II score, and/or CRP 1
• Biochemical features of multiple organ failure 1

Bacteriological Assessment:

• If sepsis is suspected, obtain microbiological examination of sputum, urine, blood, and vascular cannula tips 1

Common Pitfalls to Avoid

• Do not perform early CT routinely for staging; it may underestimate severity and is unnecessary unless management decisions depend on it 1
• Do not drain asymptomatic fluid collections; there is risk of introducing infection 1
• Do not use prophylactic antibiotics routinely; they do not improve outcomes in sterile necrosis 4, 2
• Do not delay cholecystectomy beyond 2-4 weeks in gallstone pancreatitis; recurrence risk increases dramatically 1, 6
• Do not prescribe opioids without concurrent laxatives; opioid-induced constipation is predictable and preventable 4, 5
• Do not perform urgent ERCP in gallstone pancreatitis without cholangitis or evidence of persistent CBD stone; it does not improve outcomes 2, 3