What is the evidence‑based approach to managing acute pancreatitis, including severity assessment, fluid resuscitation, pain control, nutrition, cause‑specific treatment, antibiotic use, and discharge criteria?

Practice Management of Acute Pancreatitis

Initial Diagnosis and Severity Assessment

Diagnose acute pancreatitis when at least two of three criteria are present: epigastric abdominal pain radiating to the back, serum lipase or amylase ≥3 times the upper limit of normal, and characteristic findings on CT or MRI. 1, 2

Immediate Laboratory Workup

• Obtain serum amylase or lipase, triglycerides, calcium, liver chemistries (bilirubin, AST, ALT, alkaline phosphatase), complete blood count, electrolytes, BUN, creatinine, and hematocrit at admission 1, 3
• Measure C-reactive protein at 48 hours after onset; levels >150 mg/L predict severe disease 1
• Monitor hematocrit, BUN, creatinine, and lactate as markers of adequate tissue perfusion 1, 3

Severity Stratification

• Admit patients with persistent organ failure (cardiovascular, respiratory, or renal) to an intensive care unit immediately 1, 2
• Patients with organ failure and/or systemic inflammatory response syndrome require ICU or intermediate care setting 2
• Recognize that patients with persistent organ failure plus infected necrosis have the highest mortality risk 1
• Perform CT selectively based on clinical features; reserve contrast-enhanced CT for patients with unclear diagnosis or failure to improve clinically within 72 hours 1, 2

Fluid Resuscitation

Initiate aggressive intravenous fluid resuscitation immediately with isotonic crystalloids (Ringer's lactate preferred) to optimize tissue perfusion, with the greatest benefit occurring within the first 12-24 hours. 1, 2

• Provide vigorous fluid resuscitation to all patients unless cardiovascular or renal comorbidities preclude it 1, 2
• Guide fluid administration by frequent reassessment of hemodynamic status, as fluid overload has detrimental effects 1
• Monitor hematocrit, BUN, creatinine, and lactate to assess volemia and tissue perfusion 1
• Recognize that aggressive hydration may have little benefit beyond 24 hours 2

Pain Management

Use hydromorphone as the preferred opioid for severe pain in non-intubated patients, with morphine as an acceptable alternative; no restrictions on pain medication are warranted as adequate pain control is the clinical priority. 3, 4

Pain Control Algorithm by Severity

• Mild pain: NSAIDs with or without acetaminophen (avoid NSAIDs if acute kidney injury present) 4, 5
• Moderate pain: Weak opioids (codeine or tramadol) combined with non-opioid analgesics 4
• Severe pain: Morphine or hydromorphone; integrate Patient-Controlled Analgesia (PCA) to optimize control 4
• Consider epidural analgesia for patients requiring high opioid doses for extended periods 4

Opioid-Related Management

• Routinely prescribe laxatives to prevent opioid-induced constipation 3, 4, 5
• Use metoclopramide for opioid-related nausea/vomiting 3, 4
• Note that morphine may cause sphincter of Oddi spasm, but pain relief remains the priority 4

Nutrition Management

Initiate early oral feeding immediately if no nausea or vomiting is present in mild pancreatitis; for severe cases, provide enteral nutrition (nasojejunal tube feeding with elemental or semi-elemental formula) within 48 hours rather than keeping patients NPO. 1, 3, 2

• Abandon the outdated "gut rest" approach; early enteral feeding is safe and beneficial when tolerated 3
• Reserve total parenteral nutrition only for patients unable to tolerate enteral nutrition 1
• Provide nutritional support in patients likely to remain NPO for more than 7 days 1
• Enteral nutrition prevents infectious complications and is superior to parenteral nutrition in severe disease 2, 6

Antibiotic Use

Do not use prophylactic antibiotics routinely in acute pancreatitis, even with sterile necrosis, as they do not decrease mortality or morbidity. 3, 2

• Reserve antibiotics only for confirmed infected pancreatic necrosis 3
• Use procalcitonin as the most sensitive test for detecting pancreatic infection 3
• When treating confirmed infection, use carbapenems or piperacillin/tazobactam for adequate pancreatic tissue penetration 1
• Avoid quinolones due to high worldwide resistance rates unless beta-lactam allergy exists 1

Etiology-Specific Management

Gallstone Pancreatitis

• Obtain abdominal ultrasonography at admission to screen for cholelithiasis or choledocholithiasis 1
• Perform urgent ERCP within 24 hours in patients with concurrent acute cholangitis 1, 2
• Perform early ERCP within 72 hours for high suspicion of persistent common bile duct stone (visible stone on imaging, persistently dilated CBD, jaundice) 1
• Perform cholecystectomy during the same hospital admission if possible, otherwise within 2-4 weeks after discharge 1, 5

Unexplained Pancreatitis

• Perform CT or endoscopic ultrasound (EUS) in patients >40 years old to screen for underlying pancreatic malignancy 1
• Avoid extensive evaluation in patients <40 years with single episode 1
• For recurrent episodes, evaluate with EUS and/or ERCP; prefer EUS as initial test 1

Management of Pancreatic Necrosis

Avoid surgery in patients with sterile necrosis; for infected necrosis, delay intervention for at least 4 weeks (preferably >4 weeks) to allow demarcation of necrotic tissue and lower mortality risk. 3, 2

• Recognize that sterile necrosis does not usually require therapy 1
• Use a step-up approach for infected necrosis: start with percutaneous or endoscopic drainage before proceeding to open surgical debridement 3
• Confirm infection with fine needle aspiration or radiologic evidence of gas before intervention 7
• Understand that peripancreatic fluid resolves spontaneously in more than half of cases 3

Monitoring and Complications

Provide continuous vital signs monitoring including oxygen saturation in high dependency or intensive care units for patients with organ dysfunction. 1, 3, 4

• Perform daily reassessment for development of complications including clinical, biochemical, and radiological evaluation 3
• Monitor for abdominal compartment syndrome in severe cases 1
• Perform regular arterial blood gas analysis to detect hypoxia and acidosis early in severe disease 3

Discharge Criteria and Follow-Up

Discharge patients with mild acute pancreatitis only after confirming: no organ failure, tolerating oral intake, adequate pain control on oral medications, no complications on imaging, and etiology identified and addressed. 5

Critical Discharge Requirements

• Never discharge before severity assessment is complete, as organ failure can develop after initial presentation 5
• Never delay definitive gallstone management beyond 2 weeks, as this dramatically increases recurrence risk 5
• Provide clear return precautions for worsening pain, fever, inability to tolerate oral intake, or jaundice 5
• Schedule close outpatient follow-up within 1-2 weeks to ensure complete resolution 5