Intermediate•6 min read•High Yield

Acute Pancreatitis - CCS Case Guide

Key Takeaway: Acute pancreatitis is most commonly caused by gallstones or alcohol use and presents with severe epigastric pain radiating to the back. Management centers on aggressive IV fluids, pain control, and early enteral nutrition.

Acute pancreatitis is most commonly caused by gallstones or alcohol use and presents with severe epigastric pain radiating to the back. Management centers on aggressive IV fluids, pain control, and early enteral nutrition. Severity assessment guides ICU versus floor admission.

Recognizing the Pancreatitis Presentation

  • History: Severe epigastric pain radiating to the back, worse after eating, nausea, vomiting; history of gallstones, alcohol use, or recent ERCP
  • Physical Exam: Epigastric tenderness, guarding, decreased bowel sounds, possible jaundice (gallstone), Grey Turner sign or Cullen sign in severe necrotizing pancreatitis
  • Vital Signs: Tachycardia, possible fever, hypotension in severe cases

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ IV access with aggressive fluid resuscitation (LR preferred, 250-500 mL/hr initially)
  • ✓ Pain management (IV hydromorphone or morphine, ketorolac)
  • ✓ NPO initially then early enteral nutrition as tolerated
  • ✓ Stat lipase, BMP, CBC, hepatic panel
  • ✓ Antiemetics (ondansetron)

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • Lipase (> 3x upper limit of normal diagnostic)
  • CBC with differential
  • BMP (BUN for severity scoring)
  • Hepatic panel (ALT > 150 suggests gallstone etiology)
  • CRP at 48 hours (severity marker)
  • Triglyceride level
  • Calcium level
  • Lactate
  • Right upper quadrant ultrasound (evaluate for gallstones)
  • CT abdomen with contrast (only if diagnosis uncertain or complications suspected after 48-72 hours)
  • MRCP if choledocholithiasis suspected

Treatment

Fluid Resuscitation

  • Lactated Ringer at 250-500 mL/hr for first 12-24 hours
  • Goal-directed to urine output, heart rate, and BUN improvement
  • Reassess fluid status frequently to avoid overload

Pain Management

  • IV hydromorphone or morphine (patient-controlled analgesia if severe)
  • IV ketorolac as adjunct
  • IV acetaminophen
  • Avoid meperidine (no proven benefit over other opioids)

Nutrition

  • Early enteral nutrition within 24 hours if tolerated (low-fat solid diet)
  • No need for bowel rest or clear liquid diet progression
  • Nasojejunal tube feeding if unable to tolerate oral intake
  • Avoid TPN unless enteral feeding not feasible for > 5-7 days

Gallstone Pancreatitis

  • ERCP within 24 hours if concurrent cholangitis
  • Cholecystectomy during same admission for mild pancreatitis
  • Cholecystectomy after resolution for severe pancreatitis

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Pancreatitis cases.

  • Inadequate fluid resuscitation (most common early management error)
  • Ordering CT on admission (CT is for complications, not initial diagnosis)
  • Prolonged NPO status (early feeding improves outcomes)
  • Using antibiotics prophylactically (no benefit in sterile necrosis)
  • Forgetting to obtain RUQ ultrasound for gallstone evaluation
  • Not checking triglycerides as potential etiology

Disposition

  • ICU if organ failure (BISAP >= 3 or APACHE II >= 8)
  • Floor for mild pancreatitis without organ failure
  • Discharge when pain controlled on oral medications, tolerating diet, and etiology addressed
  • GI follow-up and surgery consult for cholecystectomy if gallstone etiology

Key Orders Checklist

  • ☐ Aggressive LR infusion
  • ☐ Lipase
  • ☐ Hepatic panel
  • ☐ RUQ ultrasound
  • ☐ Pain management (IV opioids)
  • ☐ NPO then advance diet as tolerated
  • ☐ BMP every 12-24 hours

Practice Pancreatitis Cases

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