Acute Pancreatitis Management (ACG 2024)

Algorithm Steps

1. ▶

   Start

   START: Suspected Acute Pancreatitis

   Epigastric pain, nausea/vomiting

   1. ●

      Action

      Confirm Diagnosis

      Requires 2 of 3 criteria

      • 1. Characteristic abdominal pain (epigastric, radiating to back)
      • 2. Lipase (or amylase) ≥3x upper limit of normal
      • 3. CT/MRI findings consistent with pancreatitis
      • Note: Do NOT need imaging if criteria 1+2 met
      1. ●

         Action

         Determine Etiology

         Identify underlying cause

         • GALLSTONES (40%): RUQ ultrasound, LFTs (ALT >150 suggests gallstone)
         • ALCOHOL (30%): History of heavy/binge drinking
         • HYPERTRIGLYCERIDEMIA (5%): TG >1000 mg/dL
         • MEDICATIONS, post-ERCP, autoimmune, idiopathic
         • Order: LFTs, TG, calcium, RUQ US
         1. ◆

            Decision

            Severity Assessment

            Classify at admission and 48 hours

            • MILD: No organ failure, no local/systemic complications
            • MODERATE: Transient organ failure (<48h) OR local complications
            • SEVERE: Persistent organ failure (>48h)
            • Use BISAP score at admission (simple):
            • - BUN >25, Impaired mental status, SIRS, Age >60, Pleural effusion
            • - Score ≥3 = higher mortality risk
            1. ●

               Action

               Mild Pancreatitis

               Floor admission, supportive care

               • IV fluids (goal-directed)
               • Pain control (IV opioids acceptable)
               • NPO initially, then early oral feeding
               • Monitor for progression
               1. ●

                  Action

                  Fluid Resuscitation

                  Critical in first 12-24 hours

                  • GOAL-DIRECTED fluid therapy (strong recommendation)
                  • Lactated Ringer's preferred over NS
                  • Initial: 250-500 mL/hr for first 12-24 hours
                  • Target: Heart rate <120, MAP >65, UOP 0.5-1 mL/kg/hr
                  • Reassess response frequently
                  • AVOID over-resuscitation (worsens outcomes)
                  1. ●

                     Action

                     Pain Management

                     Adequate analgesia essential

                     • IV opioids are safe and effective
                     • No evidence opioids worsen outcomes
                     • Hydromorphone or morphine
                     • Consider PCA for severe pain
                     1. ◆

                        Decision

                        Gallstone Pancreatitis?

                        Determine need for ERCP/cholecystectomy

                        1. ◆

                           Decision

                           ERCP Indicated?

                           Not routine for all gallstone pancreatitis

                           • URGENT ERCP (within 24h) IF: Cholangitis present
                           • EARLY ERCP (24-72h) IF: Persistent biliary obstruction (CBD stone, dilated CBD, rising bilirubin)
                           • NO ERCP IF: Mild biliary pancreatitis without obstruction/cholangitis
                           1. ●

                              Action

                              ERCP

                              For cholangitis or persistent obstruction

                              • Urgent if cholangitis
                              • Sphincterotomy and stone extraction
                              • Stent if stone cannot be removed
                              1. ●

                                 Action

                                 Cholecystectomy

                                 To prevent recurrence

                                 • MILD gallstone pancreatitis: Same admission cholecystectomy
                                 • MODERATE-SEVERE: Delay until inflammation resolved (may be weeks)
                                 • If unfit for surgery: ERCP with sphincterotomy reduces recurrence
                                 1. ●

                                    Action

                                    Reassess at 48 Hours

                                    Re-evaluate severity and response

                                    • Repeat severity scoring
                                    • Assess fluid resuscitation adequacy
                                    • Evaluate for organ failure resolution
                                    • Plan for nutritional advancement
                                    • Specialist consultation if worsening
                                    1. ✓

                                       Outcome

                                       Resolution - Mild

                                       Discharge when tolerating oral intake

                                       • Pain controlled on oral medications
                                       • Tolerating low-fat diet
                                       • Cholecystectomy if gallstone etiology (same admission if possible)
                                       • Alcohol cessation counseling if applicable
                                    2. ✓

                                       Outcome

                                       Prolonged Course

                                       Severe/complicated pancreatitis

                                       • May require weeks of ICU care
                                       • Multidisciplinary team (GI, surgery, IR, nutrition)
                                       • Stepwise approach to necrosis management
                                       • Long-term follow-up for pancreatic insufficiency
                        2. ◆

                           Decision

                           Local Complications?

                           Assess by CT if clinically suspected

                           • Acute peripancreatic fluid collection (APFC)
                           • Acute necrotic collection (ANC)
                           • Pseudocyst (>4 weeks)
                           • Walled-off necrosis (WON, >4 weeks)
                           1. ●

                              Action

                              Necrosis Management

                              Conservative first, intervene if infected

                              • STERILE necrosis: Conservative management
                              • Prophylactic antibiotics NOT recommended
                              • INFECTED necrosis (clinical deterioration, gas on CT):
                              • - Antibiotics (carbapenems or quinolone + metronidazole)
                              • - Delay drainage if possible (>4 weeks = WON easier to drain)
                              • - Step-up approach: Percutaneous drain → endoscopic → surgical
                  2. ●

                     Action

                     Nutritional Support

                     Early enteral feeding preferred

                     • EARLY ORAL FEEDING: Within 24-48 hours if tolerated
                     • Low-fat solid diet can be started directly
                     • No need to wait for lipase normalization
                     • Enteral tube feeding if cannot tolerate oral
                     • AVOID TPN unless enteral not possible
            2. ⚠

               Warning

               Moderate-Severe Pancreatitis

               ICU consideration

               • Organ failure present or high-risk features
               • ICU admission if: Respiratory failure, shock, AKI
               • Close hemodynamic monitoring