START: Suspected Acute Pancreatitis
Epigastric pain, nausea/vomiting
All Pathways
Emergency MedicineEmergency
Acute Pancreatitis Management (ACG 2024)
Acute Pancreatitis Management (ACG 2024): START: Suspected Acute Pancreatitis → Confirm Diagnosis → Determine Etiology → Severity Assessment → Mild Panc...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action 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
03Action 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
04Decision 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
05Action Mild Pancreatitis
Floor admission, supportive care
- IV fluids (goal-directed)
- Pain control (IV opioids acceptable)
- NPO initially, then early oral feeding
- Monitor for progression
06Action 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)
07Action Pain Management
Adequate analgesia essential
- IV opioids are safe and effective
- No evidence opioids worsen outcomes
- Hydromorphone or morphine
- Consider PCA for severe pain
08Decision Gallstone Pancreatitis?
Determine need for ERCP/cholecystectomy
09Decision 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
10Action ERCP
For cholangitis or persistent obstruction
- Urgent if cholangitis
- Sphincterotomy and stone extraction
- Stent if stone cannot be removed
11Action 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
12Action 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
13Outcome 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
14Outcome 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
- Path rejoins step 11Shared downstream outcome
15Decision 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)
16Action 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
- Path rejoins step 12Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
17Action 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
- Path rejoins step 08Shared downstream outcome
18Warning Moderate-Severe Pancreatitis
ICU consideration
- Organ failure present or high-risk features
- ICU admission if: Respiratory failure, shock, AKI
- Close hemodynamic monitoring
- Path rejoins step 06Shared downstream outcome
Guideline Source
ACG Clinical Guideline: Acute Pancreatitis 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Fluid resuscitation rates should be individualized
- Severity scoring should be reassessed at 48 hours
- Local complications may need interventional radiology/surgery
- Nutritional support timing varies by patient tolerance
- ERCP indications require clinical judgment
Applicable Regions
USEUGlobal
EU: IAP/APA guidelines similar approach
US: ACG 2024 is current standard
Version 1Next review: 2028-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Acute Pancreatitis Management (ACG 2024)?
The Acute Pancreatitis Management (ACG 2024) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on ACG Clinical Guideline: Acute Pancreatitis 2024.
What guideline is the Acute Pancreatitis Management (ACG 2024) based on?
This algorithm is based on ACG Clinical Guideline: Acute Pancreatitis 2024 (DOI: 10.14309/ajg.0000000000002645).
What are the limitations of the Acute Pancreatitis Management (ACG 2024)?
Known limitations include: Fluid resuscitation rates should be individualized; Severity scoring should be reassessed at 48 hours; Local complications may need interventional radiology/surgery; Nutritional support timing varies by patient tolerance; ERCP indications require clinical judgment. Individual patient factors may require deviation from these recommendations.
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