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Pancreatitis - acute
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Exam Tips
- Diagnosis is made when at least 2 of 3 are present: typical pain, raised lipase/amylase (>3x ULN), or imaging consistent with pancreatitis.
- In UK exams, mention gallstones and alcohol first as causes, then show breadth (metabolic, drug-induced, post-ERCP, autoimmune, malignancy).
- State clearly that pain severity at presentation does not reliably predict severity; use formal severity assessment and organ-failure monitoring.
- High-yield management sequence: aggressive early IV fluids, strong analgesia, early enteral nutrition, and cause-directed intervention (for example ERCP/cholecystectomy).
- Safety point often tested: do not prescribe prophylactic antibiotics in uncomplicated or sterile necrotizing pancreatitis.
- Imaging recall: use ultrasound early for gallstones and reserve contrast CT for diagnostic uncertainty, deterioration, or suspected complications (often after 72-96 hours); see contrast CT examples of necrotizing pancreatitis in standard radiology teaching atlases.
Definition
Acute pancreatitis is a sudden inflammatory condition of the pancreas caused by premature activation of pancreatic enzymes, producing local pancreatic injury and potentially systemic organ dysfunction. Severity is defined by the revised Atlanta framework: mild disease has no organ failure or complications, moderately severe disease has transient organ failure (<48 hours) and/or local complications, and severe disease has persistent organ failure (>48 hours).
Pathophysiology
The core mechanism is intra-pancreatic activation of digestive enzymes (especially trypsin), leading to autodigestion, acinar cell injury, and a cytokine-driven inflammatory response. Gallstones can transiently obstruct the ampulla/pancreatic duct, while alcohol can promote direct acinar toxicity and altered ductal secretion; both trigger enzyme activation. In severe disease, capillary leak and systemic inflammation cause hypovolaemia and organ failure (respiratory, renal, circulatory), and local complications can include necrosis, pseudocyst, abscess, fistula formation, and vascular erosion/thrombosis.
Risk Factors
- Gallstones (commonest UK cause)
- Alcohol misuse
- Recent ERCP
- Hypertriglyceridaemia
- Hypercalcaemia
- Drugs (for example thiazides, ACE inhibitors, statins, fenofibrate, azathioprine, tetracyclines, oestrogens, corticosteroids, valproate, DPP-4 inhibitors)
- Abdominal trauma
- Recent upper abdominal/biliary surgery
- Pancreas divisum or sphincter of Oddi dysfunction
- Autoimmune disease (for example SLE, Sjogren syndrome)
- Pancreaticobiliary malignancy
- Previous pancreatitis/chronic pancreatitis
- Idiopathic (about 10%)
Clinical Features
Symptoms
- Sudden severe epigastric or upper abdominal pain, often constant and radiating to the back/flanks
- Pain worse on movement and sometimes relieved by sitting forward or knee-chest posture
- Nausea and persistent vomiting
- Anorexia
- History suggestive of biliary colic, recent alcohol excess, or prior episodes
Signs
- Epigastric or generalized abdominal tenderness
- Guarding/rebound if peritonism
- Tachycardia, hypotension, tachypnoea (possible shock)
- Fever (inflammatory response or infected complication)
- Abdominal distension/ileus
- Rare ecchymoses: Cullen, Grey-Turner, or Fox sign in haemorrhagic pancreatitis
Investigations
Serum lipase (preferred) or amylase:Typically >3 times upper limit of normal supports diagnosis in the right clinical context
Blood tests: FBC, U&E, creatinine, LFTs, CRP, glucose, calcium, triglycerides:Haemoconcentration or AKI may indicate severity; raised ALT suggests gallstone aetiology; CRP can support severity trend; hypercalcaemia/hypertriglyceridaemia may identify cause
Arterial/venous blood gas and lactate:Assesses hypoxia, acidosis, and tissue hypoperfusion in severe disease
Transabdominal ultrasound:Detects gallstones, biliary dilatation, and alternative hepatobiliary pathology
Contrast-enhanced CT abdomen (usually after 72-96 hours if severe/uncertain diagnosis):Shows necrosis, collections, and local complications; early CT may underestimate necrosis
MRCP or EUS when needed:Helps detect occult choledocholithiasis/microlithiasis when ultrasound is non-diagnostic
Severity assessment (for example NEWS2 plus Glasgow-Imrie in UK practice):Identifies patients requiring HDU/ICU escalation; pain intensity alone does not predict severity
Management
Lifestyle Modifications
- Stop alcohol and offer formal alcohol-dependence support after stabilisation
- Smoking cessation advice (reduces recurrence/progression risk)
- Early oral feeding as tolerated (enteral route preferred over prolonged starvation; use NG/NJ feeding if oral intake inadequate)
- Address cause-specific prevention: definitive gallstone management and lipid/calcium control
Pharmacological Treatment
Fluid resuscitation
- Hartmann's solution (sodium lactate compound) IV: initial bolus 500-1000 mL if hypovolaemic, then titrate (commonly ~3 mL/kg/hour initially) to urine output, haemodynamics, and biochemistry
Careful reassessment is essential to avoid fluid overload, especially in heart failure, renal impairment, and older adults.
Analgesia
- Paracetamol 1 g PO/IV every 6 hours (max 4 g/day; lower max in low body weight or liver disease)
- Morphine sulfate IV in small titrated boluses (for example 2.5-5 mg repeated according to response), then oral/SC regimen if needed
Use opioid-sparing where possible; monitor sedation and respiratory depression. Avoid/limit NSAIDs in AKI, hypovolaemia, or high GI-bleed risk.
Antiemetic therapy
- Cyclizine 50 mg PO/IM/IV up to three times daily
- Ondansetron 4 mg IV/PO every 8-12 hours when needed
Cyclizine may worsen tachycardia/urinary retention; ondansetron can prolong QT interval.
Antibiotics (only if infected necrosis, cholangitis, or another confirmed infection)
- Piperacillin/tazobactam 4.5 g IV every 8 hours (increase to every 6 hours in severe infection, renal adjustment required)
Do not give routine prophylactic antibiotics for sterile pancreatitis/sterile necrosis.
VTE prophylaxis (inpatient unless contraindicated)
- Enoxaparin 40 mg subcutaneously once daily (dose-adjust in renal impairment/low body weight)
Assess bleeding risk and renal function before prescribing.
Surgical / Interventional
- Urgent ERCP (ideally within 24 hours) for gallstone pancreatitis with acute cholangitis or persistent biliary obstruction
- Laparoscopic cholecystectomy during the same admission for mild gallstone pancreatitis (or delayed until recovery in severe disease)
- Step-up approach for infected necrosis: percutaneous or endoscopic drainage first, with delayed minimally invasive necrosectomy if required
- Drainage of symptomatic/complicated pseudocyst (usually endoscopic, case-dependent)
Complications
- Pancreatic necrosis (sterile or infected)
- Pseudocyst (typically develops after 4 weeks)
- Pancreatic abscess
- Pancreatic fistula (ascites, pleural or pericardial effusion)
- Vascular complications (splenic/portal vein thrombosis, haemorrhage from vessel erosion)
- Sepsis
- Multi-organ failure
- Acute kidney injury
- Acute respiratory distress syndrome
- Disseminated intravascular coagulation
- Recurrent acute pancreatitis and progression to chronic pancreatitis
Prognosis
Most patients (about 80-85%) have mild self-limiting disease with low mortality (around 1-3%). Moderate/severe episodes carry substantially higher mortality (roughly 13-35%), especially when infected necrosis develops. Recurrence is common after a first attack (around one-fifth), and a minority progress to chronic pancreatitis.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(4)
- Alteplase[contraindications]
- Streptokinase[contraindications]
- Tenecteplase[contraindications]
- Urokinase[contraindications]
✅NICE Guidelines(1)
- Pancreatitis - acute[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1802, 1803)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1840)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 715)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 790, 791)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 793)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 775, 776)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 716)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 776)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 829)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 825)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 829)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 829)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 341)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 621)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 991)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1000, 1001)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1222)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1149)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1058)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1146)[context]