How should I initially assess and manage a patient presenting with suspected acute pancreatitis?

Initial Assessment and Management of Suspected Acute Pancreatitis

Diagnose acute pancreatitis by confirming at least 2 of 3 criteria: characteristic epigastric pain, serum lipase elevation (preferred over amylase), and imaging findings of pancreatic inflammation. 1, 2, 3

Immediate Diagnostic Workup

Obtain these laboratory tests at presentation:

• Serum lipase (not amylase) – superior sensitivity and specificity, remains elevated longer 4, 1, 2
• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) – early elevation strongly suggests gallstone etiology 1, 2
• Serum triglycerides – levels >1000 mg/dL indicate hypertriglyceridemia as the cause 2, 5
• Serum calcium – to identify hypercalcemia as a potential etiology 2, 5
• Abdominal ultrasound immediately – to identify gallstones and assess common bile duct dilation 1, 2

Establish a definitive diagnosis within 48 hours of admission. 1, 2

Severity Stratification Within First 24-48 Hours

This determines urgency and intensity of intervention and directly impacts mortality. 1

Assess severity using these validated predictors:

• Clinical impression of severity (though lacks sensitivity, must be supported by objective measures) 4, 2
• APACHE II score >8 within first 24 hours 1, 2, 5
• Obesity (body mass index) 4, 1
• C-reactive protein >150 mg/L at 48 hours after symptom onset 4, 1, 2
• Glasgow score ≥3 (complete at 48 hours) 4, 1, 5
• Persistent organ failure beyond 48 hours – defines severe pancreatitis 4, 1

Critical distinction: Transient organ failure that resolves within 48 hours should NOT be classified as severe pancreatitis. 4, 1

Immediate Supportive Management

Initiate aggressive goal-directed intravenous fluid resuscitation immediately upon presentation – this is most beneficial within the first 12-24 hours. 1, 3, 6

• Use lactated Ringer's solution over normal saline 6
• Assess hemodynamic status immediately and begin resuscitation as needed 3
• Provide supplemental oxygen as needed 2
• Administer intravenous opiates for pain control (safe if used judiciously) 7, 8
• Correct electrolyte and metabolic abnormalities 2

All patients with severe pancreatitis (persistent organ failure, SIRS) must be managed in HDU or ICU with full monitoring including CVP, arterial blood gases, hourly vital signs, oxygen saturation, and urine output. 4, 1

Imaging for Complications

Do NOT perform early CT for staging in the first 72 hours – it underestimates the extent of necrosis and may exacerbate renal impairment with contrast. 4, 2

Obtain contrast-enhanced CT (non-ionic contrast) between days 3-10 after admission in patients with:

• Severe pancreatitis (APACHE II >8) 2
• Persistent organ failure 4, 1
• Signs of sepsis 4, 1
• Clinical deterioration 4, 1

Management of Gallstone Pancreatitis

Urgent therapeutic ERCP with sphincterotomy must be performed immediately (within 24 hours) in patients with concomitant cholangitis – delay increases morbidity and mortality. 1, 3, 6

Early ERCP (within 72 hours) is indicated for:

• Predicted or actual severe pancreatitis with suspected/proven gallstone etiology 4
• Jaundice 4, 1
• Dilated common bile duct 4, 1

All ERCPs require antibiotic cover and endoscopic sphincterotomy whether or not stones are found. 4, 1

All patients with gallbladder in situ must undergo laparoscopic cholecystectomy during the same hospital admission once clinically recovered, ideally within 2 weeks and absolutely no later than 4 weeks after discharge – delaying beyond this increases recurrent biliary events by 56%, including potentially fatal repeat pancreatitis. 1

Nutritional Support

When nutritional support is required, use the enteral route rather than total parenteral nutrition – enteral feeding protects the gut mucosal barrier and reduces bacterial translocation. 4, 1, 3

• In mild pancreatitis: Start oral feeding immediately if no nausea/vomiting 3
• In severe pancreatitis: Initiate enteral nutrition within 48 hours 6
• Nasogastric feeding is effective in 80% of cases and should be the first-line enteral method 4, 1

Antibiotic Use

Do NOT routinely administer prophylactic antibiotics in acute pancreatitis or sterile necrosis. 1, 3

Antibiotics are only indicated for:

• Specific infections (chest, urine, bile, line-related) 2
• Infected necrosis (may delay intervention and decrease mortality) 3

If antibiotics are used contrary to guidelines, limit duration to maximum 14 days. 4, 1

Management of Pancreatic Necrosis

Patients with persistent symptoms and >30% pancreatic necrosis, or smaller areas with clinical suspicion of sepsis, require image-guided fine needle aspiration to determine infection status. 4, 1

Confirmed infected necrosis mandates intervention to completely debride all necrotic cavities. 4, 1

In stable patients with infected necrosis, delay surgical, radiologic, and/or endoscopic drainage preferably for 4 weeks to allow wall formation around the necrosis. 1, 3

Specialist Referral

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or complications requiring ICU care, or interventional radiological, endoscopic, or surgical procedures. 4, 1

Critical Pitfalls to Avoid

• Never delay ERCP in patients with cholangitis – this leads to increased morbidity and mortality 1
• Never delay cholecystectomy beyond 2-4 weeks in patients fit for surgery – this significantly increases recurrent biliary events including potentially fatal repeat pancreatitis 1
• Never use parenteral nutrition when enteral feeding is tolerated 1
• Never perform CT in the first 72 hours for staging purposes – it underestimates necrosis 4, 2
• Never classify transient organ failure (<48 hours) as severe pancreatitis 4, 1