Acute Pancreatitis

Acute pancreatitis is a common cause of acute abdominal pain and hospital admission.
Most cases are mild, but some can deteriorate rapidly and become life-threatening.

This guide focuses on what doctors actually need to do on the ward and on-call.

What is acute pancreatitis?

Acute pancreatitis is inflammation of the pancreas, caused by premature activation of digestive enzymes within the gland.

In simple terms:

The pancreas starts digesting itself.

How does it present?

Typical features:

  • Severe epigastric pain (often radiates to the back)
  • Nausea and vomiting
  • Abdominal tenderness
  • Fever
  • Tachycardia

Severe features:

  • Hypotension
  • Hypoxia
  • Confusion
  • Oliguria

These suggest severe pancreatitis and need urgent escalation.

Common causes (think practically)

The two most common causes:

  • Gallstones
  • Alcohol

Always consider:

  • Recent binge drinking
  • Biliary colic history
  • Known gallstones

Other causes to remember:

  • Hypertriglyceridaemia
  • Drugs (e.g. azathioprine)
  • ERCP-related
  • Idiopathic

On the ward, always ask

Could this be gallstone-related?

Because gallstone pancreatitis often needs:

  • MRCP
  • ERCP
  • Surgical input

This affects management.

First priority = assess severity early

Acute pancreatitis is not just pain.

Assess:

  • NEWS score
  • Oxygen requirement
  • BP
  • Urine output
  • Mental state
  • Bloods (urea, creatinine, CRP)

Worsening physiology = worsening pancreatitis.

Immediate management on the ward (what juniors should actually do)

If you are called to see a patient with suspected pancreatitis:

Do early:

  • A–E assessment
  • Bloods: FBC, U&E, LFTs, CRP, calcium, glucose
  • Serum amylase (or lipase if available)
  • VBG/ABG if unwell
  • Strict fluid balance
  • Catheter if unwell

Practical steps:

  • Aggressive IV fluids (early)
  • Strong analgesia
  • Oxygen if needed
  • Antiemetics
  • Keep NBM initially
  • Early senior review if unwell

Fluids are the most important early intervention.

Imaging (real-world practice)

  • Ultrasound abdomen early (look for gallstones)
  • CT abdomen usually not on day 1 unless diagnosis unclear or patient deteriorating
  • CT typically done after 48–72 hours if severe or not improving

Don’t rush to CT in mild cases.

When to escalate

Escalate urgently if:

  • Persistent tachycardia
  • Hypotension
  • Hypoxia
  • Rising creatinine
  • Reduced urine output
  • Rising CRP
  • NEWS ≥5
  • Concerned nursing staff

These patients may need:

  • HDU/ICU
  • Gastro / surgical input

Common mistakes juniors make

  • Underestimating severity
  • Inadequate fluid resuscitation
  • Delaying escalation
  • Ordering CT too early
  • Forgetting to look for gallstones
  • Ignoring rising urea or creatinine

Take-home concept

Acute pancreatitis is not managed by amylase levels.
It is managed by recognising severity early, giving aggressive supportive care, and escalating appropriately.