European Emergency Medicine Guidelines on Acute Pancreatitis
While the evidence provided primarily reflects UK and international guidelines rather than specific European emergency medicine society recommendations, the most applicable guidance for emergency department management comes from the 2019 World Society of Emergency Surgery (WSES) guidelines, which represent international consensus including European expert input 1.
Initial Diagnosis and Assessment
Diagnose acute pancreatitis when at least two of three criteria are present: (1) abdominal pain consistent with pancreatitis, (2) serum lipase or amylase ≥3 times the upper limit of normal, or (3) characteristic findings on contrast-enhanced CT or MRI 2. Lipase is preferred over amylase for diagnosis when available 1.
Severity Stratification in the Emergency Department
Use the Revised Atlanta Classification or Determinant-based Classification to establish severity 1. Key prognostic indicators within the first 24 hours include:
- Clinical impression of severity 1
- Body mass index >30 1
- APACHE II score >8 1
- Pleural effusion on chest radiograph 1
At 48 hours after admission, reassess using:
Patients with persistent organ failure (cardiovascular, respiratory, and/or renal) have severe acute pancreatitis and should be admitted to an intensive care unit 1. This is critical because patients with persistent organ failure combined with infected necrosis have the highest mortality risk 1.
Initial Resuscitation and Management
Fluid Resuscitation
Initiate aggressive intravenous isotonic crystalloid therapy immediately, with Ringer's lactate preferred over normal saline 2, 3. The greatest benefit occurs within the first 12-24 hours 2. Target initial rates of 5-10 mL/kg/h with frequent reassessment 3. Guide fluid administration by hemodynamic monitoring to avoid fluid overload 2.
Monitor hematocrit, BUN, creatinine, and lactate serially as bedside indicators of tissue perfusion 2. Provide supplemental oxygen to maintain arterial saturation ≥95% 4.
Pain Management
Use opioid analgesics for pain control 2. Hydromorphone is preferred over morphine in non-intubated patients 2. Routinely prescribe laxatives to prevent opioid-induced constipation 2.
Antibiotic Policy
Do not administer prophylactic antibiotics routinely 1, 2, 3. High-quality randomized trials published after 2002 showed no reduction in infected necrosis or mortality with prophylactic antibiotics 2, 5. Reserve antibiotics only for documented infections 2, 5.
If antibiotic prophylaxis is used contrary to guideline recommendations, limit duration to a maximum of 14 days 1.
Imaging Strategy
Contrast-enhanced CT is the first-line imaging modality when indicated 3. However, routine early CT for staging is not recommended in the first week unless management decisions depend on the extent of necrosis 1.
Perform CT in patients with:
- Persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission 1
- Unclear diagnosis 2
- Lack of clinical improvement within 72 hours 2
When CT is performed, use the Balthazar CT severity index 1. Spiral or multislice CT with intravenous contrast (100 mL non-ionic contrast at 3 mL/s) is required 1. Non-contrast CT provides suboptimal information and should be avoided 1.
Nutritional Support
In mild pancreatitis without nausea or vomiting, start early oral feeding as soon as tolerated 2. In severe pancreatitis, initiate enteral nutrition within 48 hours rather than keeping the patient NPO 2.
When nutritional support is required, use the enteral route if tolerated 1. The nasogastric route is effective in 80% of cases 1. Reserve total parenteral nutrition for patients who cannot tolerate enteral feeding 2.
Management of Gallstone Pancreatitis
Perform abdominal ultrasonography on admission to detect gallstones or common bile duct stones 2.
Urgent ERCP within 24 hours is indicated for patients with concurrent acute cholangitis 2, 3. Early ERCP within 72 hours should be performed in patients with suspected or proven gallstone etiology who have predicted or actual severe pancreatitis, cholangitis, jaundice, or dilated common bile duct 1.
All patients undergoing early ERCP for severe gallstone pancreatitis require endoscopic sphincterotomy whether or not stones are found 1.
All patients with biliary pancreatitis should undergo definitive management of gallstones (cholecystectomy) during the same hospital admission, unless a clear plan exists for definitive treatment within 2 weeks 1, 2.
Disposition and Referral
Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1.
All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support 1.
Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis or complications who may require intensive care, interventional radiology, endoscopic procedures, or surgery 1, 5.
Critical Pitfalls to Avoid
Do not delay aggressive fluid resuscitation—early goal-directed volume replacement within the first 12-24 hours is vital 2, 4.
Do not routinely administer prophylactic antibiotics—they provide no benefit in high-quality trials 2, 4.
Do not perform routine early CT in the first week unless specific management decisions require it 1.
Do not keep patients NPO routinely—early feeding reduces the need for invasive interventions 5.