FFinalistSouthampton · 2027
Gastroenterology
AKT · Gastroenterology/Pancreatobiliary

Acute pancreatitis

Acute pancreatic inflammation (Gallstones, Ethanol the top two — 'I GET SMASHED')

Overview

Acute inflammation of the pancreas from premature enzyme activation/autodigestion. The two commonest causes are GALLSTONES and ETHANOL (the 'I GET SMASHED' mnemonic — also trauma, steroids, mumps, autoimmune, scorpion, hyperlipidaemia/hypercalcaemia, ERCP, drugs). Severe epigastric pain radiating to the back with vomiting and a raised amylase/lipase. Severity is scored (Glasgow/APACHE); management is supportive (aggressive fluids, analgesia, treat the cause). Complications: necrosis, pseudocyst, organ failure.

Recognise

  • Severe constant EPIGASTRIC pain radiating to the BACK, relieved by sitting forward, with nausea/vomiting
  • Raised serum AMYLASE (>3× upper limit) or LIPASE (more specific); epigastric tenderness; in severe disease — Cullen (periumbilical) / Grey-Turner (flank) bruising, shock, organ failure
  • Causes: Gallstones + Ethanol (commonest); also hypertriglyceridaemia, hypercalcaemia, ERCP, drugs, autoimmune, trauma, mumps

Red flags

  • Severe pancreatitis (Glasgow ≥3 / persistent organ failure) → HDU/ITU, high mortality
  • Necrotising pancreatitis/infected necrosis, pseudocyst, ARDS, AKI, hypocalcaemia

Differentials & how to tell them apart

Perforated peptic ulcersudden pain + free gas; amylase can be mildly raised — but markedly raised amylase/lipase + back radiation = pancreatitis
Acute cholecystitis/cholangitisRUQ/Murphy/jaundice; pancreatitis is epigastric-to-back
Mesenteric ischaemia / ruptured AAAvascular catastrophes — exclude in the older/at-risk
MI (inferior)ECG/troponin
Acute pancreatitis — oedematous pancreas with peripancreatic fluid/inflammation (CT)

Acute pancreatitis — oedematous pancreas with peripancreatic fluid/inflammation (CT)

Hellerhoff / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Serum AMYLASE/LIPASE (raised; lipase more specific); the Glasgow (modified) score at 48 h (PaO2, Age, WCC, Calcium, Urea, LDH, Albumin, Sugar) ± CRP. USS (gallstones — the treatable cause); LFTs; calcium/triglycerides; CT (after 48–72 h) for necrosis/complications.

Management

Aggressive IV fluids + analgesia + treat the cause; HDU/ITU if severe

  1. 1Diagnose on amylase/lipase + clinical picture. Aggressive IV fluid resuscitation, analgesia, antiemetics, early enteral nutrition. Score severity (Glasgow at 48 h) and identify the cause (USS for gallstones, lipids, calcium).Gate: Do NOT give prophylactic antibiotics routinely (only for confirmed infected necrosis); gallstone pancreatitis with cholangitis/obstruction needs urgent ERCP; severe disease (Glasgow ≥3) needs HDU/ITU
  2. 2Treat the cause (cholecystectomy for gallstone pancreatitis — same admission/within 2 weeks; abstinence; lipid/calcium control); manage complications (necrosis → step-up drainage/necrosectomy, pseudocyst, organ support).
Aggressive IV fluid resuscitation + analgesia + antiemetics — the mainstay; oxygen, nil by mouth initially, then early enteral feeding
Treat the cause — ERCP for gallstone pancreatitis with cholangitis/obstruction; cholecystectomy during/after admission; stop alcohol; treat hypertriglyceridaemia/hypercalcaemia
NO routine prophylactic antibiotics — only for confirmed infected necrosis

Key points

Epigastric pain to the back + raised amylase/lipase = acute pancreatitis; gallstones + ethanol are the top causes (I GET SMASHED). Aggressive fluids; score severity (Glasgow); NO routine antibiotics; treat the cause (ERCP/cholecystectomy for gallstones).

Monitor & prognosis

Severity score, fluids/urine output, calcium, CT for complications.

Mild self-limiting; severe/necrotising high-mortality.

Source: BSG; IAP/APA; NICE NG104