Gastrointestinal

Acute pancreatitis: severity scoring and CCS-style management

Clinical Overview and When to Suspect Acute Pancreatitis

— Acute epigastric pain radiating to back (often constant, worse supine, better leaning forward)

— Serum lipase or amylase >3× upper limit of normal

— Characteristic imaging findings (CT/MRI/US)

— ~275,000 US hospitalizations/year; leading GI cause of inpatient admission

— Mortality ~1–3% mild, up to 30% in necrotizing/infected forms

— Recurrence ~20%; progression to chronic pancreatitis ~10%

— Gallstones (~40%): female, older, ALT >150 U/L is ~95% specific

— Alcohol (~30%): typically ≥5 yrs heavy use, often binge trigger

— Hypertriglyceridemia (TG >1000 mg/dL): ~10%, suspect in DKA, pregnancy, OCP

— Post-ERCP (~3–5% of ERCPs): symptoms within 24 h

— Drugs: azathioprine, 6-MP, valproate, DPP-4 inhibitors, GLP-1 agonists, didanosine, estrogens, furosemide, thiazides, sulfonamides

— Hypercalcemia, trauma, autoimmune (IgG4), pancreas divisum, scorpion sting, viral (mumps, CMV, HIV)

— Postcholecystectomy patient with new epigastric pain → retained CBD stone

— Poorly controlled DM with milky serum and abdominal pain → hypertriglyceridemic

— Patient on TPN, recent ERCP, or new GLP-1 agonist

— Alcohol use disorder patient with relapse and vomiting

Definition (Revised Atlanta 2012): Diagnosis requires ≥2 of 3 criteria:

Epidemiology and burden

Top etiologies — "I GET SMASHED" but practically:

When to suspect on Step 3 stems:

CCS pearl: On the CCS case, opening orders for any suspected pancreatitis should include IV access × 2, NPO, IV crystalloid (LR preferred), CBC, CMP, lipase, triglycerides, calcium, LDH, ABG, type & screen, RUQ ultrasound, plus pain control. Do not order CT abdomen in the first 24–48 h unless diagnosis is uncertain — early CT underestimates necrosis and adds contrast load.

Board pearl: Lipase is preferred over amylase: more sensitive, more specific, longer half-life. Magnitude does not correlate with severity.

Presentation Patterns and Key History

— Acute, severe, steady (not colicky) epigastric pain, onset over minutes to hours

— Radiation straight through to the mid-back in ~50%

— Improved leaning forward ("pancreatic position"), worse supine

— Nausea/vomiting in >80%; vomiting does not relieve pain (vs peptic ulcer)

— Anorexia, low-grade fever, restlessness

— Gallstone: female, BMI ↑, age >50, fatty meal trigger, prior biliary colic, postcholecystectomy with retained stone

— Alcoholic: binge in setting of chronic use; ask CAGE/AUDIT-C; often recurrent admissions

— Hypertriglyceridemic: poorly controlled DM, pregnancy (3rd trimester), estrogen therapy, family history of dyslipidemia, eruptive xanthomas, lipemia retinalis

— Post-ERCP: pain within 24 h of procedure with lipase >3× ULN

— Drug-induced: new medication within weeks; review GLP-1s, DPP-4s, valproate, azathioprine, HCTZ

— Autoimmune (type 1 IgG4): painless obstructive jaundice, "sausage-shaped" pancreas, other IgG4 disease (sialadenitis, retroperitoneal fibrosis)

— Age >55, BMI >30, altered mental status, comorbid CHF/CKD

— Prior episodes, recent weight loss (suggests malignant obstruction)

— Hematochezia/melena (suggests hemorrhagic complication)

Cardinal symptom complex

Etiology-specific history clues

Red-flag historical features (severe disease prediction)

Step 3 management: Always screen for alcohol use disorder in any pancreatitis admission; document AUDIT-C and offer brief intervention plus naltrexone or acamprosate at discharge if criteria met. This is a frequently tested transition-of-care order.

Board pearl: Painless pancreatitis is rare but classic in postoperative, peritoneal dialysis, and Legionella patients. A normal lipase does not exclude pancreatitis if presentation is delayed >5–7 days — lipase can normalize while CT still shows inflammation.

Key distinction: Biliary colic = intermittent, RUQ, resolves in hours. Pancreatitis = sustained epigastric pain >24 h with enzyme elevation.

Physical Exam Findings and Hemodynamic Assessment

— Patient lying still (vs writhing in renal colic), knees drawn up, diaphoretic

— Tachypnea (>20) and shallow breathing from diaphragmatic splinting → early hypoxia

— Tachycardia (HR >100) often the first sign of third-spacing

— Hypotension (SBP <90) = SIRS/shock; resuscitate aggressively

— Fever: low-grade common early; >39°C or rising after day 5–7 suggests infected necrosis or cholangitis

— SpO₂ <95% on RA raises concern for ARDS or pleural effusion (left-sided sympathetic effusion classic)

— Epigastric tenderness with voluntary guarding; involuntary rigidity is uncommon early

— Distension from ileus; absent or hypoactive bowel sounds

— Cullen sign (periumbilical ecchymosis) and Grey-Turner sign (flank ecchymosis) — retroperitoneal hemorrhage, late (24–72 h), <5% sensitive but ominous (mortality ~37%)

— Fox sign — inguinal ligament ecchymosis (same mechanism)

— Tetany or Chvostek/Trousseau from hypocalcemia (saponification of fat)

— Jaundice — suggests gallstone with CBD obstruction or compressive head edema

— Eruptive xanthomas, lipemia retinalis — hypertriglyceridemic

— Panniculitis (subcutaneous fat necrosis) — tender erythematous nodules on legs

— Place patient on continuous monitoring; check orthostatics

— Calculate shock index (HR/SBP); >1.0 = significant volume loss

— Insert Foley if severe to target UOP >0.5 mL/kg/h

— Assess for end-organ hypoperfusion: lactate, creatinine, mental status

General appearance

Vital signs — the severity story

Abdominal exam

Systemic findings

Hemodynamic assessment (CCS-style)

CCS pearl: In the CCS environment, repeat vital signs at 2 h, 6 h, 12 h, 24 h during initial resuscitation. Worsening tachycardia or rising hematocrit despite fluids predicts severe pancreatitis and triggers ICU transfer order.

Board pearl: Hemoconcentration (Hct >44%) at admission or failure of Hct to fall at 24 h is one of the strongest predictors of necrotizing pancreatitis.

Diagnostic Workup — Initial Labs, Imaging, and Biomarkers

— Lipase >3× ULN — diagnostic gold standard; >5× more specific. Magnitude unrelated to severity.

— Amylase — rises in 6–12 h, normalizes in 3–5 days; less specific (also elevated in salivary disease, mesenteric ischemia, perforated viscus, ectopic pregnancy)

— CBC: leukocytosis common; Hct >44% = hemoconcentration → severe

— CMP: BUN >20 mg/dL or rising BUN at 24 h is the single best lab predictor of mortality

— LFTs: ALT >150 U/L is ~95% specific for gallstone etiology

— Calcium: hypocalcemia from saponification, predictor of severity

— Triglycerides: must be drawn early; falsely lowers with NPO/fluids

— Glucose, LDH, albumin — feed into scoring systems

— CRP at 48 h >150 mg/L correlates with necrosis (poor early, useful at 48 h)

— ABG/lactate: PaO₂ <60 mmHg → ARDS risk

— Procalcitonin — distinguishes infected necrosis from sterile inflammation

— Transabdominal ultrasound for every patient on admission: identifies gallstones, CBD dilation, sludge — establishes biliary etiology

— CT with IV contrast (CECT) — not routine at presentation; obtain at 72–96 h if:

— Diagnosis uncertain

— No clinical improvement after 48–72 h

— Suspected complication (necrosis, fluid collection, hemorrhage)

— MRI/MRCP preferred if CBD stone suspected without ductal dilation on US, or in pregnancy, renal failure (avoid contrast)

— CXR: look for left pleural effusion, atelectasis, ARDS

Core labs (order at presentation):

Imaging — staged approach

Key distinction: Lipase >3× ULN + characteristic pain = diagnosis. Imaging is not required to make the diagnosis if clinical and lab criteria are met. Step 3 vignettes often add an unnecessary CT — recognize that you can defer it.

Board pearl: Order fasting lipid panel in any patient with TG >500 on admission; recheck after recovery to confirm chronic hypertriglyceridemia and initiate fibrate. Always recheck LFTs at 48 h — rapidly falling ALT supports passed gallstone and may obviate ERCP.

Diagnostic Workup — Advanced and Confirmatory Studies

— MRCP — non-invasive evaluation of pancreatic and biliary ducts; detects choledocholithiasis, anatomic variants (pancreas divisum), strictures, IPMN

— Endoscopic ultrasound (EUS) — most sensitive for microlithiasis, small CBD stones missed on MRCP, periampullary lesions, chronic pancreatitis; preferred over ERCP for diagnostic workup

— ERCP — therapeutic only; reserved for documented CBD stone, cholangitis, or biliary obstruction. Carries 3–5% risk of post-ERCP pancreatitis.

— Secretin-enhanced MRCP — evaluates pancreas divisum and sphincter of Oddi dysfunction in recurrent unexplained pancreatitis

— Serum IgG4 (>2× ULN suggestive of type 1)

— ANA, RF often positive

— Imaging: diffusely enlarged "sausage" pancreas with peripheral rim

— Steroid trial diagnostic and therapeutic (40 mg prednisone × 4 wks)

— PRSS1, SPINK1, CFTR, CTRC mutations

— Recheck calcium, PTH for primary hyperparathyroidism

— Fasting triglycerides after recovery

— Balthazar CT Severity Index (CTSI): grades A–E (peripancreatic inflammation, fluid collections) + necrosis percentage (0, <30%, 30–50%, >50%)

— Score 0–10; >6 correlates with severe disease and 17% mortality

Etiology workup after initial 48 h (if cause unclear)

Autoimmune pancreatitis evaluation

Genetic and metabolic workup (recurrent or early-onset pancreatitis <35 y, family hx)

CT severity scoring

Step 3 management: For idiopathic acute pancreatitis after first episode — obtain RUQ US, fasting TG, calcium, IgG4, and review meds. After a second idiopathic episode, proceed to EUS ± MRCP to evaluate for microlithiasis, divisum, or occult neoplasm. In patients >40 with first idiopathic episode, exclude pancreatic adenocarcinoma with contrast-enhanced cross-sectional imaging.

Board pearl: Up to 75% of "idiopathic" pancreatitis is actually biliary microlithiasis detectable on EUS. Refer recurrent idiopathic cases for EUS before labeling truly idiopathic.

Risk Stratification and Severity Scoring

— Mild: no organ failure, no local/systemic complications (~80%); discharge in 3–7 days

— Moderately severe: transient organ failure (<48 h) or local/systemic complications

— Severe: persistent organ failure >48 h (single or multi-organ); mortality 20–40%

— Respiratory: PaO₂/FiO₂ <300

— Renal: Cr >1.9 mg/dL

— Cardiovascular: SBP <90 unresponsive to fluids

— BISAP (within 24 h, easy on CCS): BUN >25, Impaired mental status, SIRS ≥2, Age >60, Pleural effusion. Score ≥3 → severe disease, 5–20% mortality

— Ranson criteria: 5 at admission + 6 at 48 h; cumbersome but classic. >3 = severe

— APACHE II: ≥8 predicts severe; ICU standard

— HAPS (Harmless AP Score): no peritonitis, normal Hct, normal Cr → mild disease, predicts non-severe course with high NPV

— BUN >20 or rising at 24 h

— Hct >44 or failure to fall

— CRP >150 at 48 h

— Persistent SIRS at 48 h (HR >90, RR >20, T <36 or >38, WBC <4 or >12) — strongest clinical predictor of mortality

— Mild + tolerating PO: floor admission, early enteral feeds, biliary workup

— Moderately severe: floor with telemetry, aggressive IVF, serial labs q6–12h

— Severe / persistent SIRS / organ failure: ICU, arterial line, central access if pressors needed, consult GI and surgery early

Revised Atlanta Classification — severity grades

Organ failure defined by modified Marshall score (≥2 in any system):

Bedside scoring tools (memorize at least one)

Lab-based red flags (any one triggers closer monitoring)

Initial management decision tree

CCS pearl: On a CCS case, calculate BISAP at the 24-hour mark; if ≥3, change location to ICU, add arterial line, lactate q6h, CRP at 48 h, and consult gastroenterology and general surgery. The grader rewards timely escalation.

Board pearl: Persistent SIRS at 48 h is the single best clinical predictor of mortality — better than any composite score.

Pharmacotherapy and Supportive Care — First-Line Management

— Lactated Ringer's preferred over normal saline (reduces SIRS at 24 h; avoid LR if calcium >12 due to theoretical risk)

— Goal-directed: initial bolus 10 mL/kg if hypovolemic, then 1.5 mL/kg/h continuous infusion

— WATERFALL trial (2022) update: moderate (not aggressive) fluid resuscitation reduces fluid overload without increasing severe pancreatitis incidence — avoid >3 mL/kg/h rates routinely

— Targets at 6, 12, 24 h: HR <120, MAP >65, UOP >0.5 mL/kg/h, falling BUN and Hct, lactate clearance

— Reassess clinically every 6 h; stop aggressive fluids once goals met to prevent abdominal compartment syndrome and pulmonary edema

— IV opioids first-line: hydromorphone 0.2–0.4 mg IV q2–4h or fentanyl PCA

— Morphine acceptable (the old "sphincter of Oddi spasm" concern is not clinically significant)

— Avoid NSAIDs in severe disease (AKI risk); ketorolac fine in mild cases without renal dysfunction

— Add IV acetaminophen as opioid-sparing

— Start oral low-fat soft diet within 24–48 h in mild pancreatitis as soon as nausea/pain improve (do not wait for normalized lipase)

— Severe/moderately severe unable to eat by 72 h: nasogastric or nasojejunal enteral feeds — equivalent outcomes, NG simpler

— Avoid TPN unless enteral route fails — TPN increases infection and mortality

Fluid resuscitation — the cornerstone

Pain control

Nutrition — early enteral feeding

Antiemetics: ondansetron 4 mg IV q6h PRN

Antibiotics: NOT routine even in necrotizing pancreatitis; reserve for proven or strongly suspected infected necrosis, cholangitis, or extra-pancreatic infection. Use carbapenem (imipenem) or piperacillin-tazobactam — penetrates necrotic tissue.

Glucose control: insulin infusion if glucose >180; tight control reduces complications

Electrolyte repletion: calcium, magnesium, potassium aggressively

VTE prophylaxis: enoxaparin 40 mg SC daily unless active bleeding

CCS pearl: Order enteral nutrition consult by hour 48 in any patient not tolerating PO. On graded CCS cases, delayed nutrition costs points.

Board pearl: Prophylactic antibiotics in sterile necrosis do not improve mortality — a frequently tested negative.

Etiology-Specific and Procedural Management

— Mild gallstone pancreatitis: laparoscopic cholecystectomy during the same admission (before discharge) — reduces recurrence from 25% to <5%

— Severe/necrotizing biliary pancreatitis: delay cholecystectomy until inflammation resolves (4–6 wks); discharge with interval cholecystectomy appointment

— ERCP within 24 h: indicated only for cholangitis (Charcot triad) or persistent biliary obstruction with rising bilirubin

— Routine early ERCP in gallstone pancreatitis without cholangitis does not improve outcomes

— If unfit for surgery: ERCP with sphincterotomy as definitive prevention

— Insulin infusion (0.1–0.3 U/kg/h) with dextrose to maintain euglycemia — activates lipoprotein lipase, lowers TG ~50% in 24 h

— Apheresis (plasmapheresis) if severe disease, lactic acidosis, hypocalcemia, or organ failure — drops TG rapidly

— Heparin infusion historically used; insulin generally preferred

— Long-term: fibrate (fenofibrate) + omega-3 + dietary fat restriction <20 g/day; target TG <500

— Supportive care; thiamine 100 mg IV before glucose, folate, multivitamin

— Monitor and treat alcohol withdrawal with CIWA-Ad protocol and lorazepam

— Start naltrexone or acamprosate at discharge; refer to addiction medicine

— Step-up approach (PANTER trial): percutaneous catheter drainage → endoscopic transluminal drainage/necrosectomy → surgical necrosectomy only if needed

— Delay intervention >4 wks to allow walled-off necrosis formation

— Open necrosectomy associated with 30% mortality — last resort

— Rectal indomethacin 100 mg immediately post-ERCP in high-risk patients

— Prophylactic pancreatic duct stent in difficult cannulations

Gallstone pancreatitis

Hypertriglyceridemic pancreatitis (TG >1000)

Alcoholic pancreatitis

Necrotizing pancreatitis interventions

Post-ERCP pancreatitis prevention

Step 3 management: For mild gallstone pancreatitis, place "laparoscopic cholecystectomy this admission" on the order list within 48 h of presentation. Discharging without cholecystectomy = 25–50% recurrence within 6 weeks and a Step 3 trap answer.

Board pearl: Infected necrosis is diagnosed by gas in collection on CT or CT-guided FNA with Gram stain/culture; treat with carbapenem + minimally invasive drainage, not open surgery first.

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher mortality (3–5× baseline); more comorbid CHF, CKD, atrial fibrillation

— Atypical presentation: confusion, falls, minimal pain due to blunted visceral response

— Fluid resuscitation caution: start at 1.5 mL/kg/h LR with frequent reassessment every 2–4 h; assess for pulmonary edema and JVD before each bolus

— Lower threshold for ICU monitoring even with BISAP 2

— Polypharmacy review: discontinue offending agents (HCTZ, ACEi if AKI, statins if severe, DPP-4 inhibitors, GLP-1 agonists)

— Earlier transition to enteral feeds to prevent sarcopenia and deconditioning

— Geriatric consult and PT/OT for discharge planning; assess for delirium with CAM

— AKI in ~15% of acute pancreatitis; major mortality predictor

— Etiology: prerenal from third-spacing, ATN from sepsis, intra-abdominal hypertension

— Avoid IV contrast (delay CECT or use MRI without gadolinium if eGFR <30)

— Adjust opioid dosing: hydromorphone preferred over morphine (active metabolites accumulate in renal failure)

— Dose-adjust enoxaparin VTE prophylaxis (30 mg daily if CrCl <30) or use UFH 5000 SC BID

— Avoid NSAIDs entirely

— RRT for refractory volume overload, hyperkalemia, uremia

— Increased mortality; coagulopathy complicates procedural interventions

— Avoid acetaminophen >2 g/day; avoid NSAIDs (variceal bleed risk)

— Lower threshold for evaluating ascites infection if pre-existing

— Adjust opioid dosing and avoid benzodiazepines for sedation

— Lactulose for hepatic encephalopathy precipitated by pancreatitis-related catabolic state

— Use smaller fluid boluses (250 mL LR) with reassessment; consider POCUS for IVC and B-lines

— Continue chronic guideline-directed therapy as tolerated; hold diuretics during active resuscitation

Elderly (age >65)

Renal impairment / AKI

Hepatic impairment / cirrhosis

Heart failure

Step 3 management: In elderly or CKD patients, document paired pre- and post-bolus exam (lung auscultation, JVP, O₂ saturation) and recalculate fluid rate every 4–6 h. This pattern of cautious goal-directed resuscitation is the favored Step 3 answer over fixed-rate aggressive protocols.

Board pearl: Rising BUN at 24 h despite fluids in elderly = early ICU transfer, not more fluid bolus blindly.

Special Populations — Pregnancy, Pediatrics, and Others

— Incidence ~1 in 3000; most common in third trimester and postpartum

— Etiologies: gallstones (~70%), hypertriglyceridemia, hyperemesis-related, preeclampsia/HELLP overlap

— Diagnosis identical (lipase, US); avoid CT; use MRI/MRCP without gadolinium if cross-sectional needed

— Management: IV LR, opioids (hydromorphone or fentanyl preferred; avoid chronic morphine near delivery), early enteral nutrition

— Cholecystectomy is safe in the second trimester and recommended; first/third trimester defer to postpartum unless severe

— ERCP safe with lead shielding if cholangitis or obstruction

— Hypertriglyceridemic pancreatitis: insulin drip, plasmapheresis if needed; fibrates contraindicated in pregnancy; use omega-3 fatty acids and dietary fat restriction; gemfibrozil only postpartum

— Coordinate with MFM and obstetrics; monitor fetal heart tones

— Etiologies differ: trauma, anatomic anomalies (pancreas divisum, choledochal cyst), medications (valproate, L-asparaginase), CFTR mutations, mumps, idiopathic

— Lipase >3× ULN preferred over amylase (less reliable in children)

— Aggressive early enteral feeding within 48 h

— Refer recurrent or early-onset to genetic testing (PRSS1, SPINK1, CFTR, CTRC) and pediatric GI

— Tacrolimus and azathioprine are pancreatitis triggers — review with transplant team; do not discontinue immunosuppression unilaterally

— Consider opportunistic infections (CMV, cryptosporidium), didanosine, pentamidine

— Check CD4 and viral load

— Discontinue agent permanently after confirmed pancreatitis; document in chart and counsel patient

— Switch to alternative class (SGLT2 inhibitor, metformin, basal insulin)

Pregnancy

Pediatrics

Post-transplant patients

HIV/AIDS

Patients on GLP-1 agonists / DPP-4 inhibitors

CCS pearl: In a pregnant patient with suspected pancreatitis, opening orders should be OB consult, MFM consult, MRI/MRCP (not CT), continuous fetal monitoring if ≥24 wks gestation, and IV LR. Skipping fetal monitoring loses points.

Board pearl: Hypertriglyceridemic pancreatitis in third trimester is classic — estrogen-driven TG rise. Treat with insulin and apheresis; deliver if maternal status deteriorates.

Complications and Adverse Outcomes

— Acute peripancreatic fluid collection (APFC): <4 wks, no necrosis, no wall — most resolve spontaneously, no intervention unless symptomatic

— Pseudocyst: >4 wks, well-defined wall, no necrosis; drain only if symptomatic, infected, or >6 cm and persistent

— Acute necrotic collection (ANC): <4 wks with necrotic debris

— Walled-off necrosis (WON): >4 wks; encapsulated necrosis; intervene if infected or causing obstruction/pain

— Infected necrosis: mortality up to 30%; gas in collection on CT or positive FNA

— Hemorrhage: pseudoaneurysm of splenic/gastroduodenal artery → CT angiography + IR embolization

— Splenic vein thrombosis → sinistral portal hypertension, isolated gastric varices → splenectomy if bleeding

— Pancreatic duct disruption: persistent fluid collection, ascites, or pleural effusion with high amylase

— SIRS / sepsis / septic shock — early-phase mortality driver

— ARDS — bilateral infiltrates, PaO₂/FiO₂ <300; lung-protective ventilation

— AKI — prerenal then ATN

— Abdominal compartment syndrome: bladder pressure >20 mmHg with organ dysfunction; decompressive laparotomy if refractory

— Hypocalcemia from fat saponification → tetany, prolonged QT, seizures

— Hyperglycemia / new-onset diabetes (~25% after severe necrotizing pancreatitis)

— Exocrine insufficiency: steatorrhea, weight loss, fat-soluble vitamin deficiency; treat with pancreatic enzyme replacement (lipase 40,000–50,000 units per meal)

— DIC, ileus, pleural effusion (left > right), pericardial effusion

— Recurrence ~20%; risk halves with cholecystectomy or alcohol cessation

— Chronic pancreatitis develops in ~10% (higher with continued alcohol)

— Pancreatic adenocarcinoma risk modestly increased

Local complications (defined by Revised Atlanta)

Systemic complications

Long-term sequelae

Step 3 management: After severe pancreatitis discharge, screen for new-onset diabetes with A1c at 3 and 12 months, and check fecal elastase at 3 months if steatorrhea, weight loss, or persistent diarrhea. Both are frequently missed transitions-of-care answers.

Board pearl: Splenic vein thrombosis is the classic cause of isolated gastric varices with normal hepatic function — splenectomy is curative.

When to Escalate Care — ICU, Consults, and Triage

— Persistent organ failure >48 h (Marshall ≥2 in any system)

— BISAP ≥3, APACHE II ≥8, or CTSI ≥6

— Need for vasopressors (norepinephrine first-line)

— PaO₂ <60 mmHg or FiO₂ requirement >40%

— AKI requiring RRT or rising creatinine despite resuscitation

— Persistent SIRS at 48 h despite adequate fluids

— Hct rising despite fluids (hemoconcentration not responsive)

— Lactate >4 mmol/L

— Altered mental status, GCS <13

— Moderately severe pancreatitis without persistent organ failure

— Hypertriglyceridemic pancreatitis on insulin drip

— Elderly with comorbid CHF/CKD requiring close monitoring

— Mild pancreatitis, tolerating fluids, normal vitals, BISAP 0–1

— Gastroenterology: all moderately severe/severe cases; ERCP candidacy; necrosis intervention planning

— General/HPB surgery: gallstone etiology (cholecystectomy planning); necrosectomy if needed

— Interventional radiology: for percutaneous drainage of infected collections or pseudoaneurysm embolization

— Nutrition: all patients NPO >48 h

— Addiction medicine / social work: alcoholic pancreatitis

— Endocrinology: hypertriglyceridemic and post-pancreatitis diabetes

— MFM / OB: pregnancy

— Palliative care: prolonged ICU course, multi-organ failure

— Transfer to tertiary center if necrosectomy or advanced endoscopic intervention not available locally

— Use SBAR handoff; document fluid totals, organ failure scores, antibiotic days

ICU admission criteria (any one)

Stepdown / telemetry indications

Floor admission

Consultations (order early on CCS)

Transfer considerations

CCS pearl: On the CCS, change location to ICU as soon as you document persistent SIRS at 48 h or any single organ failure parameter — even before pressors are required. Late ICU transfer is a graded error.

Board pearl: Persistent organ failure beyond 48 h carries 30%+ mortality, vs <2% for transient organ failure — this duration cutoff drives the Atlanta classification and is heavily tested.

Key Differentials — Same-Category (GI) Causes

— Sudden onset, peritoneal signs, free air under diaphragm on upright CXR or CT

— Lipase can be mildly elevated (chemical peritonitis); usually <3× ULN

— Management: emergent surgical consult, IV PPI, broad-spectrum antibiotics

— RUQ pain (not epigastric), Murphy sign, leukocytosis, fever

— US: gallbladder wall thickening, pericholecystic fluid, sonographic Murphy

— Lipase normal or minimally elevated

— Treat: IV antibiotics + early laparoscopic cholecystectomy

— Charcot triad: fever, jaundice, RUQ pain; Reynolds pentad adds hypotension + altered mental status

— Elevated bilirubin and alkaline phosphatase out of proportion to lipase

— Emergent ERCP within 24 h plus antibiotics

— Elderly with AF, vascular disease; "pain out of proportion to exam"

— Elevated lactate, leukocytosis; CT angiography diagnostic

— Lipase can rise from pancreatic ischemia

— Surgical/IR emergency

— Crampy pain, distension, vomiting, absent flatus/BM; prior surgeries

— KUB: dilated loops with air-fluid levels

— Lipase normal

— LLQ pain (diverticulitis), CT shows fat stranding, abscess

— Lipase normal

— RUQ pain, jaundice, ALT/AST >1000 (vs gallstone pancreatitis ALT >150)

— Lipase normal unless concomitant

— Diarrhea, less severe pain, normal lipase

— Subacute pain, hypercoagulable states; CT venous phase diagnostic

Perforated peptic ulcer

Acute cholecystitis

Ascending cholangitis

Mesenteric ischemia

Small bowel obstruction

Intestinal perforation / diverticulitis

Acute hepatitis

Gastroenteritis / gastritis

Mesenteric venous thrombosis

Key distinction: ALT >150 points to gallstone pancreatitis; ALT >1000 points to viral hepatitis or ischemic hepatitis. Lipase >3× ULN almost always means pancreatitis, but macroamylasemia, renal failure, and bowel perforation can elevate it modestly.

Board pearl: Lipase elevation in DKA is real and common (~25%); pancreatitis is only diagnosed if pain plus lipase >3× ULN AND imaging supports — don't over-diagnose pancreatitis in DKA. Triglycerides may identify a true hypertriglyceridemic case.

Key Differentials — Other-Category Causes

— Epigastric pain, nausea, vomiting can mimic pancreatitis exactly

— Obtain ECG within 10 minutes of any epigastric pain in patient >40 or with cardiac risk factors

— ST elevation in II, III, aVF; troponin elevation

— Lipase normal

— Critical not to miss — anticoagulants/thrombolytics in misdiagnosed pancreatitis = disaster

— Tearing back pain, asymmetric pulses/BP, widened mediastinum

— CT angiography; emergent cardiac surgery / BP control with esmolol then nicardipine

— Mild lipase elevation possible from celiac trunk involvement

— Elderly male smoker, hypotension, pulsatile mass, back/flank pain

— Bedside US; emergent vascular surgery

— Polyuria, polydipsia, Kussmaul respirations, AG metabolic acidosis

— Lipase can be 2–3× ULN without true pancreatitis

— Check ketones, anion gap, glucose

— Hypotension, hyponatremia, hyperkalemia, abdominal pain

— Cosyntropin stimulation test; IV hydrocortisone

— Referred upper abdominal pain, especially in children/elderly

— CXR reveals consolidation

— Right-sided pleuritic pain referred to abdomen; tachypnea, hypoxia, sinus tach

— D-dimer, CTPA

— Colicky flank pain radiating to groin, hematuria, writhing patient

— Non-contrast CT abdomen

— Flank pain, fever, dysuria, CVA tenderness, pyuria

— Reproductive-age woman with abdominal pain and hypotension

— β-hCG mandatory in any reproductive-age female with abdominal pain

— Dermatomal pain preceding rash by 2–3 days

Inferior wall MI

Aortic dissection

Ruptured AAA

DKA / HHS

Adrenal crisis

Lower lobe pneumonia

Pulmonary embolism

Renal colic

Pyelonephritis

Ectopic pregnancy

Herpes zoster (pre-eruption)

Key distinction: In any patient over 40 with epigastric pain, ECG and troponin precede or accompany lipase. Missing inferior MI by anchoring on pancreatitis is a classic and dangerous error.

Board pearl: Lipase 2–3× ULN is nonspecific — consider DKA, renal failure, salivary disorders, or bowel ischemia. The diagnostic threshold for pancreatitis is >3× ULN with appropriate clinical syndrome.

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Tolerating oral low-fat diet × 24 h

— Pain controlled on oral analgesics

— No leukocytosis or fever

— Stable vitals, normalizing labs

— Etiology identified and addressed (or plan in place)

— Gallstone: cholecystectomy this admission (mild) or scheduled within 4–6 wks (severe). Without cholecystectomy, recurrence ~25–50% within 6 weeks.

— Alcohol: complete cessation; naltrexone 50 mg daily or acamprosate 666 mg TID; SMART recovery/AA referral; addiction medicine follow-up

— Hypertriglyceridemic: fenofibrate 145 mg daily, omega-3 fatty acids 4 g daily, dietary fat <20 g/day, tight glycemic control if diabetic, weight loss, alcohol cessation, hold estrogens. Target TG <500.

— Drug-induced: permanently discontinue offending agent; document allergy/adverse reaction; counsel on avoidance. Switch GLP-1/DPP-4 patients to SGLT2 or basal insulin.

— Hypercalcemia: workup parathyroid; parathyroidectomy if primary hyperparathyroidism

— Autoimmune: prednisone 40 mg daily × 4 wks then taper; rituximab if relapsing

— Post-ERCP: rectal indomethacin and pancreatic duct stenting at future procedures

— Pancreatic enzyme replacement (PERT) if steatorrhea: lipase 40,000–50,000 U with meals, 20,000 U with snacks; titrate to symptoms

— Fat-soluble vitamin supplementation (A, D, E, K)

— PPI alongside PERT to optimize enzyme activity

— Insulin for type 3c (pancreatogenic) diabetes; basal-bolus regimen

— Calcium and vitamin D supplementation

— Routine: influenza, COVID, pneumococcal in alcoholic pancreatitis

— Hepatitis A/B in alcohol use disorder

— Smoking cessation (independent risk factor for chronic pancreatitis progression)

— Weight loss and Mediterranean-style low-fat diet

Discharge criteria

Etiology-specific secondary prevention

Post-necrotizing pancreatitis discharge meds

Vaccinations

Counseling

Step 3 management: At discharge, the highest-yield Step 3 orders are: (1) cholecystectomy scheduled if biliary, (2) fibrate + omega-3 + diet if hypertriglyceridemic, (3) naltrexone + AUD counseling if alcoholic, (4) PERT + A1c if necrotizing. Pick the etiology-matched bundle.

Board pearl: Failure to perform same-admission cholecystectomy in mild gallstone pancreatitis is a tested error of management.

Follow-Up, Monitoring Parameters, and Rehabilitation

— PCP visit within 1–2 weeks of discharge to review medication reconciliation, pain control, diet tolerance, and pending labs

— Gastroenterology follow-up at 4–6 weeks for moderately severe and severe cases; sooner if symptomatic fluid collections

— Repeat CT or MRI at 4–6 weeks if necrosis or fluid collections present at discharge — assess for walled-off necrosis or persistent pseudocyst requiring drainage

— Surgery follow-up within 2 weeks if interval cholecystectomy planned

— Symptoms: persistent or recurrent epigastric pain, early satiety, steatorrhea, weight loss, fevers

— Labs at follow-up: CMP, lipid panel (fasting TG if hypertriglyceridemic etiology), CBC, A1c at 3 and 12 months, fecal elastase at 3 months if steatorrhea suspected (<200 µg/g = insufficiency)

— Imaging: repeat cross-sectional imaging if symptoms persist or pseudocyst was present

— Bone density (DEXA) at 1–2 years in chronic pancreatitis or fat malabsorption (osteoporosis risk ~25%)

— Nutrition counseling: low-fat (<30% kcal), small frequent meals, avoid binge eating

— Alcohol abstinence is non-negotiable; document at each visit

— Smoking cessation counseling at every visit; offer varenicline or NRT

— Physical therapy after prolonged ICU stay for deconditioning, sarcopenia

— Mental health screening — PTSD and depression common after ICU stay (PHQ-9, PCL-5)

— Hypertriglyceridemic: fasting lipid every 3 months until target met, then every 6–12 months

— Post-necrotizing: monitor for type 3c diabetes annually; signs of exocrine insufficiency

— Autoimmune pancreatitis: IgG4 levels every 3–6 months; monitor for relapse

— Recurrent idiopathic >40 yo: consider repeat imaging at 6–12 months to exclude occult pancreatic adenocarcinoma

— Warning signs requiring return: severe abdominal pain, vomiting, fever, jaundice, dark urine, oily stools, unexplained weight loss

Outpatient follow-up cadence

Monitoring parameters

Rehabilitation and lifestyle

Specific surveillance

Patient education

Step 3 management: A complete discharge plan includes PCP follow-up within 2 weeks, specialty follow-up at 4–6 weeks, A1c and fecal elastase at 3 months, and interval cholecystectomy scheduled. Stems will offer an incomplete plan — pick the one with all transitions of care addressed.

Board pearl: New-onset diabetes within 3 years of acute pancreatitis in patient >50 should prompt evaluation for pancreatic cancer.

Ethical, Legal, and Patient Safety Considerations

— Disclose 3–5% post-ERCP pancreatitis risk, plus bleeding, perforation, cholangitis, sedation risks

— Document alternative options (MRCP for diagnosis, surgical CBD exploration) and rationale for ERCP

— Use teach-back method to confirm comprehension; engage interpreter if LEP

— Do not withhold opioid analgesia from patients with AUD; undertreated pain is unethical and worsens outcomes

— Offer medication-assisted treatment (naltrexone, acamprosate) — failure to offer is a quality measure gap

— Confidentiality: substance use records have heightened protection under 42 CFR Part 2; obtain specific consent for disclosure

— Patients with alcohol intoxication or hepatic encephalopathy may lack decision-making capacity; reassess when clear

— Document four elements: understanding, appreciation, reasoning, expressing a choice

— A patient refusing cholecystectomy after gallstone pancreatitis must have capacity confirmed and risks of recurrence (25–50%) clearly documented

— High-risk handoff: ICU-to-floor and hospital-to-home are the highest-risk moments

— Use standardized SBAR at every handoff; explicit medication reconciliation

— Schedule follow-up appointments before discharge; do not rely on patient to call

— Communicate with PCP within 48 h via secure message or discharge summary

— Confirm transportation, medication access, and language-concordant instructions

— Refeeding syndrome in malnourished patients (alcoholics): start with 50% kcal goal, supplement thiamine 100 mg IV before feeds, monitor phosphate/magnesium/potassium daily × 3 days

— Opioid stewardship at discharge: prescribe limited supply (3–7 days), avoid long-acting opioids, screen for OUD risk, co-prescribe naloxone for AUD patients

— Anticoagulation pause for procedures must be reconciled — failure to restart enoxaparin causes hospital-acquired VTE

— Drug-induced pancreatitis from suspected medication errors → report to MedWatch

— Suspected non-accidental trauma in pediatric pancreatitis → report to child protective services

Informed consent for ERCP

Alcohol use disorder — ethical pitfalls

Capacity assessment

Transition-of-care safety

Pancreatitis-specific safety events

Mandatory reporting and public health

Step 3 management: When a patient with alcoholic pancreatitis demands discharge AMA, perform capacity assessment, document risks (recurrence, infected necrosis, death), arrange close follow-up, prescribe naltrexone, and provide naloxone. Do not refuse care or threaten the patient.

Board pearl: Failing to schedule interval cholecystectomy is both a clinical error and a documented patient-safety event — flagged on Step 3 stems.

High-Yield Associations and Rapid-Fire Facts

— ALT >150 U/L → gallstone etiology (95% specific)

— TG >1000 mg/dL → hypertriglyceridemic

— Calcium >12 mg/dL → hyperparathyroidism

— IgG4 elevated, sausage pancreas → autoimmune type 1

— Recent ERCP within 24 h → post-ERCP pancreatitis

— Eruptive xanthomas, lipemia retinalis → familial hypertriglyceridemia

— Painless obstructive jaundice + sausage pancreas → autoimmune pancreatitis (not adenocarcinoma)

— Lipase magnitude does NOT correlate with severity

— BUN >20 or rising = strongest single mortality predictor

— Hct >44 = hemoconcentration, predicts necrosis

— Persistent SIRS at 48 h = best clinical mortality predictor

— CRP >150 at 48 h correlates with necrosis

— Hypocalcemia from saponification = severe disease marker

— Do not order CT in first 48 h unless diagnostic uncertainty

— MRCP > ERCP for diagnostic biliary evaluation

— Gas in fluid collection = infected necrosis until proven otherwise

— LR > NS (reduces SIRS at 24 h)

— Moderate (not aggressive) fluid resuscitation per WATERFALL trial

— Early enteral feeding within 24–48 h

— NO prophylactic antibiotics in sterile necrosis

— Same-admission cholecystectomy for mild gallstone pancreatitis

— Insulin drip for hypertriglyceridemic pancreatitis

— Step-up approach for necrosectomy; delay >4 wks

— Diuretics (furosemide, HCTZ)

— Reverse-transcriptase inhibitors (didanosine)

— Uremic agents - 5-ASA, mesalamine

— GLP-1 agonists, DPP-4 inhibitors

— Steroids, sulfonamides

— Pentamidine

— Azathioprine, 6-MP, asparaginase

— Naproxen (rare), NRTIs

— Captopril, statins (rare)

— Valproate

— Local: APFC, pseudocyst, ANC, WON, infected necrosis, hemorrhage, splenic vein thrombosis, duct disruption

— Systemic: SIRS, ARDS, AKI, ACS, hypocalcemia, hyperglycemia

Etiology pearls

Lab pearls

Imaging pearls

Management pearls

Drug-induced pancreatitis ("DRUGS in PANC")

Complications mnemonic

Board pearl: Pancreatic adenocarcinoma should be considered in any patient >40 years old with "idiopathic" pancreatitis — obtain contrast-enhanced cross-sectional imaging and EUS to evaluate.

Board Question Stem Patterns

— 55F obese with epigastric pain, lipase 1200, ALT 220, US with stones, improving on day 3

— Best next step: laparoscopic cholecystectomy this admission (not discharge with outpatient follow-up)

— 32F third trimester, DM, milky serum, lipase 800, TG 3500

— Management: insulin infusion + dextrose, NPO, consider apheresis, MFM consult, defer fibrate until postpartum

— Day 3 with rising BUN, persistent tachycardia, new hypoxia, Hct 48

— Action: ICU transfer, recalculate BISAP, obtain CECT, consider necrosis; do NOT add antibiotics empirically

— Pancreatitis with fever, jaundice, hypotension, AMS

— Diagnosis: ascending cholangitis (Reynolds pentad) → ERCP within 24 h + broad-spectrum antibiotics

— Patient with severe pancreatitis 6 wks ago returns with fever, abdominal pain

— CT shows walled-off necrosis with gas → infected WON → carbapenem + endoscopic transluminal drainage (step-up approach), NOT open necrosectomy first

— 45M with second episode, normal US, no alcohol, TG normal

— Next step: EUS to evaluate for microlithiasis, pancreas divisum, occult neoplasm

— Patient with glucose 600, ketones, AG, lipase 250 (1.5× ULN), mild epigastric pain

— Most likely: DKA with nonspecific lipase elevation, not pancreatitis — treat DKA; reassess

— Type 2 DM on semaglutide presents with pancreatitis after dose increase

— Action: discontinue GLP-1 permanently, switch to SGLT2 inhibitor or basal insulin, document adverse reaction

— Severe pancreatitis with new isolated gastric varices and splenomegaly

— Diagnosis: splenic vein thrombosis → splenectomy if bleeding

— Alcoholic patient wants to leave; assess capacity, document risks, prescribe naltrexone, arrange addiction follow-up, provide naloxone — do not refuse care

Pattern 1 — The mild gallstone pancreatitis dispo question

Pattern 2 — The hypertriglyceridemic crisis

Pattern 3 — The deteriorating patient at 48 h

Pattern 4 — The cholangitis overlap

Pattern 5 — The post-discharge return

Pattern 6 — The recurrent idiopathic case

Pattern 7 — The DKA distractor

Pattern 8 — The drug-induced case

Pattern 9 — The complication question

Pattern 10 — The AMA discharge scenario

Board pearl: Step 3 favors etiology-specific, transition-aware answers. When two answers seem clinically equivalent, pick the one that includes follow-up cadence or definitive prevention (e.g., cholecystectomy, fibrate, naltrexone).

One-Line Recap

Acute pancreatitis is a clinical diagnosis (pain + lipase >3× ULN + supportive imaging) where outcomes depend less on enzyme magnitude than on early severity stratification (BISAP, persistent SIRS, BUN trend), goal-directed lactated Ringer's resuscitation, early enteral nutrition, etiology-specific definitive prevention (same-admission cholecystectomy for gallstones, insulin/fibrate for hypertriglyceridemia, naltrexone for alcohol), and disciplined avoidance of low-value interventions like routine early CT, prophylactic antibiotics in sterile necrosis, and TPN.

Diagnosis: 2 of 3 — characteristic pain, lipase >3× ULN, imaging. Skip CT in first 48 h unless diagnostic uncertainty or no improvement.

Severity & resuscitation: Calculate BISAP at 24 h; persistent SIRS at 48 h or organ failure >48 h → ICU. Use LR at ~1.5 mL/kg/h with reassessment q6h targeting MAP >65, UOP >0.5 mL/kg/h, falling BUN/Hct.

Etiology-driven definitive care: Mild gallstone → cholecystectomy same admission. Hypertriglyceridemic → insulin drip ± apheresis, then fenofibrate + omega-3. Alcohol → thiamine, CIWA, naltrexone/acamprosate, addiction referral. Drug-induced → permanent discontinuation. Necrotizing infected → carbapenem + step-up minimally invasive drainage, delayed >4 wks.

Transitions of care: PCP at 1–2 wks, GI at 4–6 wks, A1c and fecal elastase at 3 months, interval cholecystectomy scheduled, AUD/lipid surveillance — these are the Step 3-winning order sets.

CCS pearl: Open every case with IV access, NPO, LR infusion, lipase, CBC, CMP, TG, calcium, RUQ US, pain control, VTE prophylaxis; reassess vitals q2–6h; escalate location promptly when severity criteria emerge; close the loop with etiology-specific discharge bundle.