Acute pancreatitis

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 resuscitation^[1]
Lactated Ringer's preferred over normal saline (reduces SIRS); 5–10 mL/kg/h initial, individualised by haemodynamic response and lactate; avoid aggressive 'one-size-fits-all' over-resuscitation per WATERFALL trial
Early oral feeding when tolerated^[1]
Restart oral diet (low-fat solid food) as soon as tolerated, typically within 24 h; nasogastric or jejunal feeding if oral not tolerated by 72 h; total parenteral nutrition only if enteral not feasible
Aetiology-targeted treatment^[1]
Gallstone pancreatitis with cholangitis: ERCP within 24 h. Mild gallstone pancreatitis: cholecystectomy during same admission. Hypertriglyceridaemia >1000 mg/dL: insulin infusion ± apheresis. Alcohol: cessation support
Avoid prophylactic antibiotic in sterile necrosis^[1]
No antibiotic prophylaxis for sterile necrosis; reserve for infected necrosis (clinical deterioration, rising markers, gas on CT, positive culture from CT/EUS-guided FNA)
Step-up approach for infected necrosis^[1]
First: percutaneous or endoscopic drainage; escalate to minimally invasive necrosectomy (video-assisted retroperitoneal debridement, endoscopic transluminal) if drainage insufficient; open surgery only as last resort
Index admission cholecystectomy for mild gallstone pancreatitis^[1]
Definitively prevents recurrence; do not delay to outpatient — significant readmission risk; severe pancreatitis: cholecystectomy after recovery (4–6 weeks) to allow inflammation resolution

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Lactated Ringer's solution (resuscitation)^[1]	Balanced isotonic crystalloid	5–10 mL/kg/h initial, individualised; reassess every 6 h with vital signs, urine output, haematocrit, BUN, lactate	Per paediatric protocols	Preferred over normal saline; reduces SIRS and may reduce severe outcomes; avoid over-resuscitation (abdominal compartment syndrome, ARDS)
Analgesia — tramadol or low-dose opioid^[1]	Analgesic	Tramadol 50–100 mg PO/IV every 6 h; morphine 2–5 mg IV PRN; or fentanyl PCA in ICU	—	Adequate analgesia is essential; older textbooks advised against morphine for sphincter of Oddi spasm — modern evidence supports any opioid; avoid NSAIDs in AKI risk
Piperacillin-tazobactam or meropenem (infected necrosis)^[1]	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	Reserve for documented or strongly suspected infected necrosis; both penetrate pancreatic tissue well; narrow per culture; antifungal cover if recurrent or persistent
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)^[1]

Balanced isotonic crystalloid

Adult: 5–10 mL/kg/h initial, individualised; reassess every 6 h with vital signs, urine output, haematocrit, BUN, lactate
Paediatric: Per paediatric protocols

Preferred over normal saline; reduces SIRS and may reduce severe outcomes; avoid over-resuscitation (abdominal compartment syndrome, ARDS)

Analgesia — tramadol or low-dose opioid^[1]

Analgesic

Adult: Tramadol 50–100 mg PO/IV every 6 h; morphine 2–5 mg IV PRN; or fentanyl PCA in ICU
Paediatric: —

Adequate analgesia is essential; older textbooks advised against morphine for sphincter of Oddi spasm — modern evidence supports any opioid; avoid NSAIDs in AKI risk

Piperacillin-tazobactam or meropenem (infected necrosis)^[1]

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

Reserve for documented or strongly suspected infected necrosis; both penetrate pancreatic tissue well; narrow per culture; antifungal cover if recurrent or persistent

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.

References

1.WSES Guidelines for the Management of Severe Acute Pancreatitis (2019); ACG Clinical Guideline Acute Pancreatitis (2024); Atlanta classification 2012 (2024)