Acute pancreatitis is an acute inflammatory process of the pancreas with variable involvement of peripancreatic tissues and remote organ systems 1,2. According to the Revised Atlanta Classification, diagnosis requires at least two of the following three features: characteristic epigastric pain radiating to the back, serum lipase or amylase activity at least three times the upper limit of normal, and characteristic findings on cross-sectional imaging 1.

Aetiology (I GET SMASHED)

  • gallstones (40–50% of cases): transient ampullary obstruction by biliary microlithiasis or calculi; suggested by ALT >150 U/L within 48 hours of onset 1,2

  • alcohol (25–35% of cases)

  • other causes: hypertriglyceridaemia (>11.3 mmol/L / 1000 mg/dL), post-ERCP, hypercalcaemia, drugs (azathioprine, valproate, thiazides), autoimmune (IgG4-related disease), scorpion envenomation, trauma

Clinical presentation

Patients present with sudden, severe epigastric pain radiating straight through to the mid-back, relieved partially by sitting forward, accompanied by nausea and vomiting 1,2. Severe retroperitoneal haemorrhage may produce Cullen sign (periumbilical ecchymosis) or Grey Turner sign (flank ecchymosis) 2.

Classification of Severity (Revised Atlanta Classification)

  • mild acute pancreatitis: no organ failure and no local or systemic complications

  • moderately severe acute pancreatitis: transient organ failure (<48 hours) and/or local complications (acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection, or walled-off necrosis) 1

  • severe acute pancreatitis: persistent organ failure (>48 hours) involving the respiratory, cardiovascular, or renal systems (Modified Marshall score ≥2) 1

Management

  • goal-directed fluid resuscitation: balanced crystalloid (Hartmann / Ringer lactate solution preferred over 0.9% saline) at moderative rates to maintain urine output >0.5 mL/kg/hr 2

  • early enteral nutrition: oral or nasogastric/nasojejunal feeding within 24–48 hours preserves gut mucosal integrity and reduces bacterial translocation; prophylactic antibiotics are not recommended for sterile necrosis 1,2

  • biliary decompression: urgent ERCP within 24 hours if concomitant acute cholangitis is present; index-admission laparoscopic cholecystectomy for mild gallstone pancreatitis 1,2