Diagnose and grade by revised Atlanta, moderate fluids (WATERFALL), early enteral feeding, no prophylactic antibiotics, and the step-up approach to infected necrosis.
At the bedside
- 1
Confirm and find the cause
Lipase (or amylase), USG abdomen for gallstones, triglycerides (> 1,000 mg/dL), calcium, alcohol history, drugs, ERCP/trauma. CT only if diagnosis uncertain or deterioration after 72-96 h.
- 2
Predict severity
BISAP (BUN > 25 mg/dL, i.e. urea > 53 mg/dL, impaired mental status, SIRS, age > 60, pleural effusion; ≥ 3 = high risk), SIRS persisting > 48 h, haematocrit, urea trend; monitor organ failure (modified Marshall).
- 3
Moderate, goal-directed fluids
0-72 hRinger lactate: 10 mL/kg bolus if hypovolaemic, then 1.5 mL/kg/h; reassess at 3, 12, 24, 48, 72 h. Avoid aggressive fluids (WATERFALL: more overload, no benefit).
- 4
Analgesia
Paracetamol + opioids (fentanyl/morphine as needed); epidural in selected patients.
- 5
Feed early
≤ 72 hOral diet as tolerated within 24-72 h; if not tolerated, enteral via nasogastric or nasojejunal tube (equivalent). Avoid TPN unless enteral fails.
- 6
Antibiotics only for infection
No prophylactic antibiotics in sterile necrosis. Suspect infected necrosis if deterioration/fever after 7-10 days or gas in necrosis on CT: carbapenem/quinolone + metronidazole, FNA if unclear.
- 7
Biliary: ERCP if cholangitis
Urgent ERCP (< 24 h) for cholangitis; not routinely for gallstone pancreatitis without obstruction. Cholecystectomy in same admission for mild biliary pancreatitis.
- 8
Step-up for infected necrosis
Antibiotics first; delay intervention ≥ 4 weeks (walled-off necrosis) if possible; percutaneous or endoscopic drainage, then minimally invasive necrosectomy if needed. Monitor IAP.
Moderate fluid resuscitation
Ringer lactate
- Dose
- 10 mL/kg bolus if hypovolaemic, then 1.5 mL/kg/h
- Worked example
- 70 kg, hypovolaemic: 700 mL bolus, then 105 mL/h; reassess at 3 h (stop at 48 h if tolerating oral)
Reduce if signs of overload.
Revised Atlanta severity
| Grade | Organ failure | Complications |
|---|---|---|
| Mild | None | None |
| Moderately severe | Transient (< 48 h) | Local (collections, necrosis) or exacerbation of comorbidity |
| Severe | Persistent (> 48 h), single or multiple | Usually present |
Local complications (Atlanta)
| < 4 weeks | > 4 weeks (encapsulated) |
|---|---|
| Acute peripancreatic fluid collection (interstitial) | Pseudocyst |
| Acute necrotic collection (necrotising) | Walled-off necrosis (WON) |
References
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Acute pancreatitis: first 72 h
Step 1 of ~8
Assess organ failure (Marshall), BISAP, SIRS; USG for gallstones
Based on Tenner S, Vege SS, Sheth SG, et al; de-Madaria E, Buxbaum JL, Maisonneuve P, et al. Educational use; follow local protocol.
Pathophysiology
Premature activation of trypsin within acinar cells causes autodigestion, local inflammation and a systemic inflammatory response with capillary leak, leading to organ failure. Necrosis may become infected (translocation) usually after the first week.
Evidence
- WATERFALL (2022): aggressive vs moderate LR resuscitation - more fluid overload (20.5% vs 6.3%) without improving outcomes; stopped early [de-Madaria 2022].
- PANTER (2010): step-up approach reduced major complications or death vs open necrosectomy [van Santvoort 2010].
- ACG 2024 guideline: moderate fluids, early oral feeding, no prophylactic antibiotics, delayed intervention for necrosis [Tenner 2024].
Controversies
- Optimal fluid in severe pancreatitis already in organ failure (WATERFALL excluded these).
🇮🇳 India notes
- Alcohol is the leading cause in Indian men, gallstones in women; tropical (idiopathic) chronic pancreatitis is a regional entity.
- Endoscopic necrosectomy expertise exists at major Indian centres (e.g. AIG Hyderabad).
References
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