START: Suspected acute pancreatitis (adult)
Constant epigastric or left upper quadrant pain, often to the back; nausea, vomiting
All Pathways
Emergency MedicineEmergency
Acute Pancreatitis Management (ACG 2024)
Acute Pancreatitis Management (ACG 2024): START: Suspected acute pancreatitis (adult) → Confirm diagnosis: 2 of 3 criteria → Find the cause → Assess sev...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Confirm diagnosis: 2 of 3 criteria
Typical pain; lipase or amylase more than 3 times ULN; typical imaging. Pregnant: early obstetric and gastroenterology advice; prefer ultrasound or MRI to CT.
- 1. Pain consistent with AP (epigastric or LUQ, often radiating to the back)
- 2. Serum lipase (or amylase) more than 3 times the upper limit of normal
- 3. Characteristic findings on CT, MRI or ultrasound
- No routine CT at admission to assess severity. CT only if the diagnosis is unclear or no improvement at 48-72 h
- Lipase can also rise in perforation, bowel ischaemia and other acute abdomens: do an ECG; CT if peritonism or an atypical picture
- Dull, colicky or lower abdominal pain suggests another cause
03Action Find the cause
Abdominal ultrasound for gallstones in all patients; LFTs, triglycerides, calcium
- Transabdominal ultrasound in all; repeat if inconclusive
- Most common: gallstones (40-70%) and alcohol (25-35%)
- No gallstones and no significant alcohol use: check triglycerides. Above 11.3 mmol/L (1,000 mg/dL) supports hypertriglyceridaemia as the cause
- Age over 40 with no cause found: consider a pancreatic tumour
- Drugs, hypercalcaemia and infection are rare causes; attribute them with caution
- Idiopathic: repeat ultrasound, MRI/MRCP or EUS
04Action Assess severity: organ failure, SIRS, risk features
Organ failure: SBP below 90 mmHg, PaO2 below 60 mmHg (or PaO2/FiO2 300 or less on oxygen), or creatinine above 177 µmol/L after fluids. Assess at admission and repeat over 48 h.
- SIRS: 2 or more of HR above 90/min; RR above 20/min or PaCO2 below 32 mmHg; temp above 38 °C or below 36 °C; WCC above 12 or below 4 x10^9/L
- High-risk features: age over 55, BMI over 30, altered mental state, comorbid disease
- Urea above 7.1 mmol/L or rising; haematocrit above 0.44 or rising; raised creatinine
- Pleural effusion, pulmonary infiltrates, or multiple or extensive collections
- No score or scan reliably predicts severe AP; stay alert for 48 h
05Warning Organ failure or SIRS: monitored bed or ICU
None of these: ward care, but watch closely for organ failure over the first 48 h
- ICU if shock, respiratory failure or AKI
- Organ failure lasting more than 48 h = severe AP
- Organ failure or SIRS: early review by gastroenterology, surgery and ICU
06Action IV fluids from presentation: moderate rate, not aggressive
Start at presentation, alongside the work-up. Adults. Shock or respiratory failure: resuscitate with ICU, guided by frequent reassessment; the moderate regimen was tested only in patients without them. Older age, heart failure or CKD: lower rates and check often for fluid overload.
- Hartmann's (compound sodium lactate) preferred over normal saline
- Adult with hypovolaemia: 10 mL/kg bolus over 2 h; repeat only if still hypovolaemic
- Then up to 1.5 mL/kg/h. Most adults need about 3-4 L in the first 24 h, depending on body size; more only if still hypovolaemic
- Reassess within 6 h, then often for 24-48 h: HR, BP, urine output; aim for falling urea and haematocrit
- Reduce or stop if overload: pulmonary oedema, abdominal compartment syndrome. Stop IV fluids once eating and drinking and not hypovolaemic
- After 24 h or once severe: aggressive fluids give no benefit and can harm
07Action Analgesia
Treat pain early: paracetamol, and IV opioid for severe pain. Avoid NSAIDs in AKI or CKD. AKI or older age: lower opioid doses and titrate slowly.
- Avoid NSAIDs in AKI or CKD
- Titrate IV opioid to effect; consider PCA for severe pain
- AKI: morphine metabolites accumulate; use lower, less frequent doses
- Step down analgesia as pain settles
08Action Nutrition: early oral feeding
Mild AP: low-fat solid diet within 24-48 h as tolerated
- Start when no significant nausea, vomiting or ileus; do not wait for pain or enzymes to settle
- Moderately severe or severe AP: enteral feeding if oral intake fails; nasogastric route is acceptable
- Predicted severe AP: tube feeding within 24 h gives no benefit over on-demand feeding
- Avoid parenteral nutrition unless enteral feeding is not possible, not tolerated or not enough
09Action Treat the cause
Alcohol: withdrawal risk and thiamine. High triglycerides: specialist advice.
- Alcohol: assess and treat alcohol withdrawal; give thiamine
- Triglycerides above 11.3 mmol/L: seek endocrine or lipid advice; repeat fasting triglycerides 1 month after discharge
- Hypercalcaemia: find and treat the cause
- Stop any drug suspected of causing AP
10Decision Gallstone (biliary) pancreatitis?
Gallstones or sludge on ultrasound, or raised ALT or bilirubin
- If Yes
11Decision Cholangitis or persistent bile duct stone?
Cholangitis: IV antibiotics now and ERCP within 24 h. No cholangitis: no early ERCP; ERCP only for a persistent CBD stone.
- No cholangitis: medical therapy rather than ERCP in the first 72 h
- Persistent CBD stone: rising bilirubin or stone seen on imaging
- CBD stone suspected without cholangitis or jaundice: MRCP or EUS first; avoid diagnostic ERCP
- If Yes
12Action Cholangitis or persistent CBD stone: ERCP
Cholangitis: blood cultures and IV antibiotics now, then ERCP within 24 h
- Cholangitis: start IV antibiotics as soon as it is diagnosed (per local guidelines, such as Therapeutic Guidelines); this is treatment, not prophylaxis
- Septic shock: resuscitate, antibiotics, urgent biliary drainage
- Sphincterotomy and stone extraction
- Stent if the stone cannot be removed
- Still refer for cholecystectomy after sphincterotomy
13Action Biliary AP: cholecystectomy
Mild: same admission, before discharge. Necrosis, peripancreatic collections or severe AP: delay and plan with the surgeon.
- Mild biliary AP: cholecystectomy before discharge (18% readmitted with biliary events if delayed)
- Normal bilirubin: laparoscopic cholecystectomy with intraoperative cholangiogram
- Necrosis, peripancreatic collections or severe AP: delay until collections resolve or stabilise and inflammation settles; timing set by surgeon and gastroenterologist
- Unfit for surgery: ERCP with biliary sphincterotomy lowers recurrence
14Decision All patients: necrosis or collection on CT?
Contrast CT if no improvement at 48-72 h or a complication is suspected
- Acute peripancreatic fluid collection or acute necrotic collection (first 4 weeks)
- Pseudocyst or walled-off necrosis (after 4 weeks)
- If Yes
15Action Necrosis or collection: conservative first
No prophylactic antibiotics. Stable: delay any drainage, preferably 4 weeks.
- Sterile necrosis: no antibiotics
- Suspected infected necrosis (gas on CT, deterioration): antibiotic that penetrates necrosis, such as a carbapenem, per local guidance; no routine FNA
- Infected necrosis, stable: antibiotics; delay drainage, preferably 4 weeks, for the wall to mature
- Unstable or not improving: urgent review with surgery, IR and endoscopy
- Minimally invasive step-up (endoscopic or percutaneous drainage by anatomy, then necrosectomy) over open surgery
- No routine antifungals
16Decision Improving at 48-72 h?
Repeat severity assessment and review fluids, organ function and feeding
- Mild: no organ failure and no local complications
- Moderately severe: organ failure that resolves within 48 h, or local complications
- Severe: organ failure lasting more than 48 h
- If Yes
17Outcome Improving: plan discharge
Pain controlled on oral analgesia and tolerating a low-fat diet. Mild biliary AP: cholecystectomy before discharge.
- Mild biliary AP: cholecystectomy before discharge. Necrosis, peripancreatic collections or severe AP: delay; timing set by the surgeon
- Alcohol: brief intervention and referral
- Second episode with no cause, fit for surgery: consider cholecystectomy
- Idiopathic AP: further tests (ultrasound, MRI/MRCP or EUS)
If No18Outcome Not improving or complicated: specialist care
New or persistent organ failure: ICU. Complications: multidisciplinary team.
- May need weeks of ICU or hospital care
- Team: gastroenterology, surgery, IR, ICU, dietitian
- Follow up for diabetes and exocrine insufficiency
If No- Path rejoins step 16Shared downstream outcome
If No- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 14Shared downstream outcome
Guideline Source
American College of Gastroenterology Guidelines: Management of Acute Pancreatitis (Tenner et al, 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Children and pregnancy need specialist advice and local protocols.
- Fluid rates are a starting point. Reassess often; use lower rates in older patients, heart failure and CKD.
- No score or scan reliably predicts severe AP; reassess over the first 48-72 h.
- Timing of ERCP, cholecystectomy and necrosis drainage needs specialist judgement.
- Treatment of hypertriglyceridaemia-induced AP follows local protocols.
Contraindicated Populations
pediatric
Applicable Regions
AUUSEUGlobal
AU: Hartmann's solution = compound sodium lactate (lactated Ringer's). Urea, triglycerides in mmol/L; creatinine in µmol/L.
EU: IAP/APA evidence-based guidelines take a similar approach
US: ACG 2024 guideline
Version 2Next review: 2027-09-30
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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 American College of Gastroenterology Guidelines: Management of Acute Pancreatitis (Tenner et al, 2024).
What guideline is the Acute Pancreatitis Management (ACG 2024) based on?
This algorithm is based on American College of Gastroenterology Guidelines: Management of Acute Pancreatitis (Tenner et al, 2024) (DOI: 10.14309/ajg.0000000000002645).
What are the limitations of the Acute Pancreatitis Management (ACG 2024)?
Known limitations include: Adults only. Children and pregnancy need specialist advice and local protocols.; Fluid rates are a starting point. Reassess often; use lower rates in older patients, heart failure and CKD.; No score or scan reliably predicts severe AP; reassess over the first 48-72 h.; Timing of ERCP, cholecystectomy and necrosis drainage needs specialist judgement.; Treatment of hypertriglyceridaemia-induced AP follows local protocols.. Individual patient factors may require deviation from these recommendations.
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