Acute Pancreatitis

Acute pancreatitis: epigastric pain radiating to back, elevated amylase/lipase (>3x normal), or CT showing pancreatic inflammation. Severity: - Mild (no organ failure, no necrosis) - Moderately severe (transient <48h organ failure) - Severe…

BSG Guidelines / Glasgow Scoring

The pathway

1 · Diagnosis & severity scoring

Amylase/lipase >3x ULN or CT pancreatic inflammation. Glasgow score (3+ of 8 = severe): age >55, WBC >15, glucose >10, urea >16, pO₂ <8, calcium <2, albumin <32, LDH >600. Check within 48h of admission. CTSI (CT Severity Index) if severe or not improving by 48–72h.

2 · Aggressive IV fluid resuscitation

500ml crystalloid (Hartmann's preferred) bolus stat. Then 250–500ml/hr for first 12–24h. Hartmann's reduces systemic inflammation vs normal saline. Urine output target >0.5ml/kg/hr. Fluid balance chart. Avoid oliguria at all costs.

3 · Analgesia

Morphine 5–10mg IM/IV — evidence does not support withholding opioids in pancreatitis. PCA if severe. Consider epidural in ITU patients. Paracetamol regular. NSAIDs avoid (AKI risk). Adequate analgesia reduces respiratory splinting.

4 · Nutrition

Mild: oral intake when tolerated — early refeeding reduces complications
Severe/not tolerating oral: nasojejunal (NJ) feeding preferred over TPN — maintains gut integrity, reduces infection. Start within 48h. TPN only if NJ not tolerated or accessible.

5 · Cause investigation

Gallstones: USS abdomen at admission. If gallstone pancreatitis: urgent ERCP within 24–72h if cholangitis/CBD obstruction. Elective cholecystectomy before discharge (prevents recurrence). Alcohol: AUDIT-C, CAGE score, safe drinking advice, thiamine.

6 · Complications monitoring

Pseudocyst (4+ weeks), abscess, necrosis (CT at 72h if severe), ARDS, AKI. SIRS criteria daily. Infected necrosis: CT-guided aspiration, antibiotics (imipenem/meropenem). Organ failure developing → ITU transfer urgently.

Drugs

Drug	Dose	Route	Notes
Hartmann's solution	500ml bolus then 250ml/hr	IV	Preferred crystalloid. Target UO >0.5ml/kg/hr. Reassess frequently.
Morphine	5–10mg 4-hourly PRN	IM/IV	Do NOT withhold opioids. PCA for severe pain.
Piperacillin-tazobactam	4.5g 8-hourly	IV	Only for infected necrosis or concurrent cholangitis — not prophylactic antibiotics.
Thiamine	100mg TDS	PO/IV	If alcohol-related — prevent Wernicke's.

When to escalate

Glasgow score ≥3 at 48h → HDU admission,Organ failure (renal, respiratory, cardiovascular) → ITU,CBD obstruction + cholangitis → ERCP within 24h,CT necrosis + clinical deterioration → interventional radiology/surgery,Rising CRP >150 at 48h → CT abdomen for CTSI severity

Reference: BSG Guidelines for Management of Acute Pancreatitis 2018

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