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Acute pancreatitis
Most get better with fluids and time — your job is to spot the ones who won't. Confirm the diagnosis, score the severity, give careful fluids and good analgesia, find the cause (gallstones or alcohol usually), and watch for organ failure. Built for revision, not live patient decisions.
Settle them, and check the basics
diagnose · resuscitateRed flags — what each should make you think
Amylase and lipase don't tell you how severe it is. The severity is in the patient: organ failure, fluid needs, lactate, oxygen. And check for an alternative diagnosis (perforation, AAA, MI, mesenteric ischaemia), which can also raise amylase.
First actions
- IVIV fluids
- 💊Analgesia
- O₂Oxygen if hypoxic
- UOMonitor urine output
- USSAbdominal ultrasound
- 🍽Early feeding
Understand the patient
diagnose · score · causeDiagnosis — 2 of 3
- Typical upper abdominal pain, often radiating to the back
- Lipase or amylase at least 3× the upper limit of normal
- Characteristic imaging findings (CT/MRI/USS)
Severity
- Glasgow-Imrie (within 48 h) — PaO₂ below 8 kPa, Age over 55, Neutrophils (WCC above 15), Calcium below 2, Renal (urea above 16), Enzymes (LDH above 600 or AST above 200), Albumin below 32, Sugar (glucose above 10). Score ≥3 = severe
- Revised Atlanta — mild (no organ failure), moderately severe (transient organ failure under 48 h or local complications), severe (persistent organ failure over 48 h)
- CRP above 150 at 48 h also suggests severe disease
Causes ("I GET SMASHED")
- Gallstones and alcohol cause most cases
- Idiopathic, trauma, steroids, mumps/viruses, autoimmune, scorpion venom, hypertriglyceridaemia/hypercalcaemia, ERCP, drugs (azathioprine, thiazides, valproate, GLP-1 agonists)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Persistent organ failure (respiratory, renal, cardiovascular) beyond 48 h.
Clinical scores, lactate, ABG, U&E.
HDU/ITU, careful fluids, nutrition support, CT at 72 h or later if not improving (necrosis, collections).
Fever, rigors, jaundice, RUQ pain, rising bilirubin.
LFTs, USS/MRCP (dilated duct).
IV antibiotics and ERCP — NICE: ERCP within 72 h for gallstone pancreatitis with biliary obstruction; urgently if cholangitis.
Deterioration after the first week, fever, rising inflammatory markers.
CT (gas in necrosis).
Antibiotics, step-up approach (drainage, then endoscopic or surgical necrosectomy) in a specialist centre. No prophylactic antibiotics early on.
Peritonism, pulsatile mass, pain out of proportion, ECG changes.
Erect CXR, CT, ECG, troponin.
Treat the actual cause; these are surgical/cardiac emergencies.
Investigate — what to order, when, and what it tells you
test with a question in mindBloods
Ultrasound
CT
MRCP / EUS
How the plan comes together
disposition · handoversurgical / medical ward
Mild–moderate: fluids, analgesia, early feeding. Gallstone pancreatitis: cholecystectomy during the same admission (or within 2 weeks) if mild. Alcohol: brief intervention, support, withdrawal management.
HDU / ITU
Organ failure, high scores, rising lactate, hypoxia.
Hand over: severity score, fluid balance, organ function, cause, imaging plan.
Diagnose it on 2 of 3, score it, give careful fluids and good analgesia, find the cause, and watch for organ failure and cholangitis. No prophylactic antibiotics and no early CT unless the diagnosis is in doubt. Nicely done getting here.
Clerking template
copy or downloadAcute pancreatitis — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for acute pancreatitis?
- Persistent organ failure (over 48 h) — think severe pancreatitis
- Rigors, jaundice, deranged LFTs — think cholangitis — urgent ERCP
- Hypotension, rising lactate — think shock / SIRS
- Hypoxia — think ARDS
- Rigid abdomen — think perforation (mimic)
- Pain radiating to back + shock in older patient — think ruptured AAA (mimic)
What is the initial management of acute pancreatitis?
- IV fluids — balanced crystalloid, goal-directed (avoid over-aggressive fluids)
- Analgesia — IV opioids as needed — adequate pain relief is important
- Oxygen if hypoxic — target 94–98%
- Monitor urine output — catheter if severe
- Abdominal ultrasound — look for gallstones
- Early feeding — oral as tolerated; enteral if severe and not eating
Always alongside senior support and your local guideline.
What diagnoses must you not miss in acute pancreatitis?
- Severe pancreatitis — organ failure
- Cholangitis / obstructed gallstone pancreatitis — jaundice · fever
- Infected necrosis — week 2+ deterioration
- Mimics — perforation · AAA · mesenteric · MI
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for acute pancreatitis?
- Bloods — Lipase (preferred) or amylase.
- Ultrasound — Early — gallstones, duct dilatation.
- CT — Diagnostic doubt at presentation, or not improving after 72 h (necrosis, collections). Not routinely early.
- MRCP / EUS — Suspected stones not seen on USS.
Admit or discharge: how is the plan decided for acute pancreatitis?
- Surgical / medical ward — Mild–moderate: fluids, analgesia, early feeding. Gallstone pancreatitis: cholecystectomy during the same admission (or within 2 weeks) if mild. Alcohol: brief intervention, support, withdrawal management.
- Hdu / itu — Organ failure, high scores, rising lactate, hypoxia.
Is there a clerking template for acute pancreatitis?
Yes — there is a clerking template for acute pancreatitis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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