ACUTE PANCREATITIS
Epigastric Abdominal pain
((2 /3 of the following - consistent clinical presentation, lipase >3x ULN, imaging c/w pancreatitis))

  • SX: epigastric pain radiating to the back, worse after eating, Anorexia +N/V, Denies ((chest pain, RUQ colicky pain, hematemesis/melena,fever))

  • Hx: gallstones, alcohol use, hyperTG, ± prior episodes, recent ERCP

  • PE: epigastric tenderness

  • W/U: Lipase (≥3× ULN),CBC (↑WBC), CMP (BUN/Cr, Ca, LFTs (ALT >150 → gallstones), Mag and Phos (AUD), TG level (>1000), RUQ US → gallstones level, CT A/P w/contrast (if unclear or severe sx or fever)

  • MEDS:

  • DDX: Cholecystitis / biliary colic, Peptic ulcer disease

  • cause: gallstones, alcohol, hypertriglyceridemia, ERCP, .

Plan

  • NPO → early feeding within 24–48 hrs if tolerated, will start clear liquid or soft and advance as tolerated; tube feeds if no PO intake at 5-7 days

  • Fluids: 10mL/kg bolus of LR followed by 1.5cc/kg/hr in first 24 hours ≈3-4 L

  • Pain: Acetaminophen ± Oxycodone 5-10mg q6 PRN with hydromorphone 0.2-1 mg q2 PRN for breakthrough

  • Antiemetics ordered

  • if Alcohol related ->thiamine(200mg IV 3-5 days then 100mg 3x daily for 1 to 2 weeks and  MVT/Prenatal 

  • Daily CBC,RFP and Mg, replete the K, Mg, PO4 accordingly

  • Tele 

  • PT/OT 

  • trend fever curve and hemodynamics (distributive shock from SIRS-mediated vasoplegia,)

  • Monitor for complications (ARDS, infected pancreatic necrosis, sterile pancreatic necrosis, and pancreatic pseudocyst).

  • SW consult  if needed

  • strict I/Os UOP goal >0.5 mL/kg/hr

  • monitor for Complications (ARDS,Infected pancreatic necrosis (worsening sx and decline, fever, ↑ WBC, CT ABd, IR for drainage,Abx broad) ,sterile Pancreatic necrosis (On CT but no systematic sx, tx Supportive only, IR if infection) and Pseudocyst (CT with CT fluid collection, if Sx/obstruction/>6cm consult IR for drainage)

  • GI-> consider ERCP if Acute cholangitis or Ongoing CBD obstruction

  • Surgery-> consider laparoscopic cholecystectomy during the same admission for Mild gallstone pancreatitis

  • IR / Surgery for complications (necrosis, pseudocyst)

  • if Severe/necrotizing pancreatitis or peripancreatic collections: will delay cholecystectomyuntil the inflammation/collections settle, often around 6 to 10 weeks after onset

  • if Hypertriglyceridemia-induced, in addition Tx with an insulin drip (0.1-0.3 U/kg/hr) regardless of blood sugar, monitor glucose q1h, add D5 if <100 mg/dL, should Lower TG 50–80% in 24–48h by activating lipoprotein lipase. if Severe cases (TG >1000 mg/dL, organ failure, necrosis Plasmapheresis 1–3 sessions; rapid TG drop (70% per session) but expensive, invasive. for BOTH Continue until TG <500, Start enteral nutrition (fat-free initially) once stable. Oral fibrates (e.g., fenofibrate) + statin once tolerating PO.

Note: ↑WBC 2/2 Reflects systemic inflammation / stress response.

  • ☐ CBC daily

  • ☐ CMP (BUN/Cr, Ca, LFTs) daily

  • ☐ Mg, Phos daily

  • ☐ Triglycerides

  • ☐ ± Lactate (if sick)

  • ☐ Strict I/Os

  • ☐ RUQ ultrasound

  • ☐ CT A/P w/ contrast if:

    • unclear diagnosis

    • no improvement after 2–3 days

    • concern for complications

  • ☐ LR bolus 10 mL/kg (if hypovolemic)

  • ☐ Then LR ~1.5 mL/kg/hr (~3–4 L first 24h)

  • ☐ NPO initially

  • ☐ Start PO within 24–48 hrs → clear → advance as tolerated

  • ☐ Acetaminophen (APAP)

  • ☐ Oxycodone 5–10 mg when PO tolerated

  • ☐ Hydromorphone (Dilaudid) IV for now

  • ☐ Ondansetron (Zofran)

  • ☐ PT/OT

  • ☐ If AUD:

    • ☐ Thiamine 200 mg IV x3–5 days → 100 mg PO TID x1–2 weeks

    • ☐ Multivitamin / prenatal vitamin

  • ☐ GI consult (if obstruction / ERCP consideration)

  • ☐ Surgery → cholecystectomy (if mild gallstone pancreatitis)

  • ☐ IR / Surgery consult for complications (necrosis, pseudocyst)