Red Flags
- Severe pancreatitis with persistent organ failure (>48 h) or sepsis — admit to ICU; goal-directed therapy; multidisciplinary team[1]
- Cholangitis with pancreatitis (fever, jaundice, raised LFTs) — emergency ERCP within 24 h; broad-spectrum antibiotic[1]
- Infected pancreatic necrosis (fever, rising inflammatory markers, gas on imaging at 2–4 weeks) — step-up minimally invasive drainage; broad-spectrum antibiotic guided by culture[1]
- Abdominal compartment syndrome (intra-abdominal pressure >20 mmHg with new organ dysfunction) — surgical decompression after medical optimisation[1]
First-line treatment
Interventions
- Goal-directed fluid resuscitationUse early isotonic crystalloid resuscitation guided by frequent reassessment of hemodynamics and perfusion, avoiding fluid overload. Individualize volume for age, weight and pre-existing renal or cardiac disease. WSES 2019 regards evidence for lactated Ringer’s superiority over normal saline as weak and does not specify a universal 5–10 mL/kg/hour rate. [2]
- Early oral feeding when toleratedUse enteral nutrition to maintain gut integrity; both gastric and jejunal feeding are acceptable. Avoid total parenteral nutrition when enteral feeding is feasible; partial parenteral supplementation may be considered if enteral intake is insufficient. The 2019 WSES statement does not mandate the stored 24/72-hour feeding deadlines. [2]
- Aetiology-targeted treatmentERCP is indicated for acute gallstone pancreatitis with cholangitis or common-bile-duct obstruction. Perform cholecystectomy during the index admission for mild gallstone pancreatitis. Triglycerides>1000 mg/dL suggest a hypertriglyceridemic cause, but this guideline does not establish an insulin/apheresis dosing pathway. [2]
- Avoid prophylactic antibiotic in sterile necrosisDo not give prophylactic antibiotics for sterile pancreatic necrosis. Treat suspected or proven infected necrosis, recognizing that inflammatory deterioration can mimic infection. Gas in a collection supports infection; CT-guided FNA can confirm it but is no longer routinely used. [2]
- Step-up approach for infected necrosisFor deteriorating patients with suspected infected necrosis, use a step-up approach starting with percutaneous or endoscopic drainage and escalate when necessary. Prefer intervention after necrosis becomes walled off, usually around 4 weeks, when clinical circumstances permit. Separate complications can require surgery, including abdominal compartment syndrome not controlled by conservative measures, bleeding after unsuccessful endovascular control, or bowel ischemia. Earlier emergency surgery does not itself call for routine drainage or necrosectomy. [2]
- Index admission cholecystectomy for mild gallstone pancreatitisPerform index-admission cholecystectomy for mild gallstone pancreatitis, including after ERCP/sphincterotomy because other biliary complications remain possible. With peripancreatic fluid collections, defer cholecystectomy until collections resolve or stabilize and acute inflammation ceases; this is not a fixed 4–6-week rule. [2]
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Lactated Ringer's solution (resuscitation) | Balanced isotonic crystalloid | Individualize isotonic crystalloid volume to perfusion response, age, weight and renal/cardiac disease; reassess frequently, including hemodynamics, hematocrit, BUN, creatinine and lactate. No universal infusion rate is specified in this source. [2] | Per paediatric protocols | Use isotonic crystalloids with frequent reassessment and avoid fluid overload. WSES 2019 considers the evidence that lactated Ringer’s is superior to normal saline weak. [2] |
| Analgesia — tramadol or low-dose opioid | Analgesic | Tramadol 50–100 mg PO/IV every 6 h; morphine 2–5 mg IV PRN; or fentanyl PCA in ICU | — | Provide adequate analgesia; WSES 2019 identifies no evidence to restrict the analgesic class. Avoid NSAIDs in acute kidney injury. Consider epidural analgesia within a multimodal strategy when appropriate. [2] |
| Piperacillin-tazobactam or meropenem (infected necrosis) | Beta-lactam ± beta-lactamase inhibitor / carbapenem | Piperacillin-tazobactam 4.5 g IV every 6–8 h; meropenem 1 g IV every 8 h | Per local protocol | For infected necrosis, select antibiotics that penetrate necrosis and cover likely aerobic and anaerobic Gram-positive and Gram-negative organisms. Piperacillin/tazobactam has intermediate pancreatic penetration with broad coverage; carbapenems have good penetration but should be reserved for very critically ill patients. Do not routinely give prophylactic antifungal treatment. [2] |
| Insulin infusion (hypertriglyceridaemic pancreatitis)[1] | Insulin therapy | Regular insulin 0.1–0.2 U/kg/h IV with concurrent glucose to maintain euglycaemia, until triglycerides <500 mg/dL | — | Hypertriglyceridaemia >1000 mg/dL precipitating pancreatitis; consider plasmapheresis in severe; dietary fat restriction and fenofibrate after recovery |
Lactated Ringer's solution (resuscitation)
Balanced isotonic crystalloid
- Adult
- Individualize isotonic crystalloid volume to perfusion response, age, weight and renal/cardiac disease; reassess frequently, including hemodynamics, hematocrit, BUN, creatinine and lactate. No universal infusion rate is specified in this source. [2]
- Paediatric
- Per paediatric protocols
Use isotonic crystalloids with frequent reassessment and avoid fluid overload. WSES 2019 considers the evidence that lactated Ringer’s is superior to normal saline weak. [2]
Analgesia — tramadol or low-dose opioid
Analgesic
- Adult
- Tramadol 50–100 mg PO/IV every 6 h; morphine 2–5 mg IV PRN; or fentanyl PCA in ICU
- Paediatric
- —
Provide adequate analgesia; WSES 2019 identifies no evidence to restrict the analgesic class. Avoid NSAIDs in acute kidney injury. Consider epidural analgesia within a multimodal strategy when appropriate. [2]
Piperacillin-tazobactam or meropenem (infected necrosis)
Beta-lactam ± beta-lactamase inhibitor / carbapenem
- Adult
- Piperacillin-tazobactam 4.5 g IV every 6–8 h; meropenem 1 g IV every 8 h
- Paediatric
- Per local protocol
For infected necrosis, select antibiotics that penetrate necrosis and cover likely aerobic and anaerobic Gram-positive and Gram-negative organisms. Piperacillin/tazobactam has intermediate pancreatic penetration with broad coverage; carbapenems have good penetration but should be reserved for very critically ill patients. Do not routinely give prophylactic antifungal treatment. [2]
Insulin infusion (hypertriglyceridaemic pancreatitis)[1]
Insulin therapy
- Adult
- Regular insulin 0.1–0.2 U/kg/h IV with concurrent glucose to maintain euglycaemia, until triglycerides <500 mg/dL
- Paediatric
- —
Hypertriglyceridaemia >1000 mg/dL precipitating pancreatitis; consider plasmapheresis in severe; dietary fat restriction and fenofibrate after recovery
Safety-net
- Stop alcohol completely — recurrence and progression to chronic pancreatitis are common[1]
- Worsening pain, fever, vomiting, jaundice, or new symptoms during recovery — same-day medical review (complications can present late)[1]
- Take statin and fenofibrate as prescribed if hypertriglyceridaemic; avoid high-fat meals and uncontrolled diabetes[1]
Referral criteria
- Severe acute pancreatitis (persistent organ failure ≥48 h, infected necrosis, severe sepsis)ICU and tertiary HBP service[1]
- Cholangitis with pancreatitisEmergency ERCP within 24 h[1]
- Walled-off necrosis or symptomatic pseudocyst at 4+ weeksTertiary HBP / interventional endoscopy or interventional radiology[1]
- Hypertriglyceridaemic or recurrent idiopathic pancreatitisEndocrinology / HBP for metabolic workup and prevention[1]
Clinical summary
Diagnosis, severity stratification, fluid resuscitation, and complications management of acute pancreatitis in adults.