Acute Pancreatitis

Based on real-life application of guidance from
National Institute for Health and Care Excellence (NICE) and
British Society of Gastroenterology (BSG)

Translated into:

👉 what you actually do when clerking and managing a patient
👉 not textbook theory

Because most harm in pancreatitis comes from:

  • poor fluids
  • late escalation
  • unnecessary antibiotics
  • missing gallstones/cholangitis

✅ First principle (most important)

Acute pancreatitis management is:

Supportive care + fluids + monitoring

There is no magic drug.

Good basics save lives.

✅ Step 1 – Confirm the diagnosis

You only need 2 of 3:

1. Typical pain

  • severe epigastric
  • radiates to back
  • vomiting

2. Raised amylase/lipase

3× normal

3. Imaging consistent

Usually pain + amylase is enough.

👉 Don’t delay treatment waiting for CT.

✅ Step 2 – Immediate management (first hours)

This is where juniors make the biggest difference.

Do immediately

A–E assessment

IV access (2 cannulas)

Bloods

  • FBC
  • U&E
  • LFTs
  • CRP
  • Calcium
  • Glucose
  • ABG/VBG
  • Group & save

Fluids (most important treatment)

👉 aggressive IV fluids (e.g. Hartmann’s)

Pancreatitis patients are very dehydrated.

Poor fluids = worse outcomes.

Analgesia

Opiates often needed
Don’t under-treat pain

NBM initially

Oxygen if needed

✅ Step 3 – Look for the cause early

Because cause determines next step.

Ask:

The big three causes (most common in NHS)

  • Gallstones
  • Alcohol
  • Idiopathic

Together = ~80–90%

Check:

  • Alcohol history
  • LFTs (ALT/ALP/bilirubin)
  • Ultrasound liver

Why ultrasound?

To look for:
👉 gallstones or bile duct obstruction

Should be done within 24 hours.

🚨 Step 4 – Identify severe pancreatitis early

Most cases are mild.

Some deteriorate fast.

Your job = spot the sick ones early.

Red flags for severe disease

  • Hypotension
  • Tachycardia
  • Oliguria
  • Hypoxia
  • Rising urea
  • High CRP (>150)
  • Confusion
  • Elderly/comorbid

👉 escalate early (HDU/ICU + seniors)

Do NOT manage these alone on ward.

✅ Step 5 – Antibiotics? (very common question)

❌ Do NOT give routine antibiotics

Pancreatitis is inflammatory, not infectious.

Antibiotics do NOT improve outcomes.

Only give if:

  • cholangitis
  • infected necrosis
  • sepsis from another source

Otherwise → no antibiotics.

Very common mistake.

✅ Step 6 – When to scan?

CT scan timing

❌ Not immediately

Early CT often normal and misleading

✅ After 72 hours (if needed)

If:

  • diagnosis unclear
  • not improving
  • severe disease
  • complications suspected

CT is for complications, not diagnosis.

🚨 Step 7 – When to involve gastro/ERCP?

Very exam + ward relevant.

If gallstone pancreatitis + cholangitis or obstruction

  • jaundice
  • fever
  • dilated ducts

👉 urgent ERCP

Because:
Obstructed infected duct = emergency

If gallstones but stable

👉 ERCP not needed immediately
👉 plan cholecystectomy during same admission or soon after

✅ Step 8 – Feeding

Old teaching = prolonged NBM (wrong).

Start oral/enteral feeding early

As soon as tolerated

Improves outcomes.

Avoid unnecessary starvation.

✅ Step 9 – Ongoing monitoring

Daily:

  • U&E
  • CRP
  • fluid balance
  • urine output
  • obs

Watch for:

  • AKI
  • hypocalcaemia
  • sepsis
  • respiratory failure

Most complications show up here first.

✅ Practical ward scenarios

Scenario 1

Alcohol binge + amylase 1500
→ fluids + analgesia + supportive care

Scenario 2

Gallstones + jaundice + fever
→ cholangitis
→ urgent ERCP

Scenario 3

Mild pancreatitis improving
→ early feeding
→ discharge soon

Scenario 4

Day 3 worsening pain + sepsis
→ CT scan for necrosis

Scenario 5

Started antibiotics “just in case”
→ unnecessary
→ stop

❌ Common junior mistakes

  • Under-resuscitating fluids
  • Giving antibiotics routinely
  • Doing CT too early
  • Forgetting ultrasound
  • Missing cholangitis
  • Keeping NBM too long
  • Late escalation of severe cases

Most problems are management errors, not diagnosis errors.

✅ Simple on-call algorithm (easy memory)

When you see pancreatitis:

1️⃣ Fluids
2️⃣ Analgesia
3️⃣ Bloods
4️⃣ Ultrasound
5️⃣ Monitor severity
6️⃣ Antibiotics only if infection
7️⃣ ERCP only if obstruction/cholangitis

That’s 95% of care.

✅ Take-home concept

Acute pancreatitis is treated with fluids and supportive care, not drugs.
The two things you must not miss are severe disease and cholangitis.

If you remember those, you’ll manage safely.