Severe pancreatitis: persistent organ failure (over 48 h), rising lactate, or necrosis. Needs critical care and a specialist pancreatic pathway. Most deaths are from organ failure, not the pain.
Diagnosis (2 of 3)
- Epigastric pain radiating to the back
- Lipase or amylase at least 3 times the upper limit
- Characteristic findings on cross-sectional imaging
Causes (I GET SMASHED)
- Gallstones and alcohol account for most cases
- Hypertriglyceridaemia, hypercalcaemia, drugs, ERCP
- Always get an USS to look for gallstones
Mild
- No organ failure or complications
- IV fluids, analgesia, early feeding
- Most resolve within a week
Moderately severe
- Transient organ failure (under 48 h)
- Local complications
- HDU, monitor
Severe
- Persistent organ failure (over 48 h)
- Glasgow 3 or more, rising CRP
- Critical care, nutrition plan
Early management
1
1. Resuscitate
Early balanced crystalloid titrated to urine output and observations (avoid over-filling). Oxygen, analgesia, antiemetic. Antibiotics only for proven infection, not routinely.
Early balanced crystalloid titrated to urine output and observations (avoid over-filling). Oxygen, analgesia, antiemetic. Antibiotics only for proven infection, not routinely.
↓
2
2. Score severity
Modified Glasgow (at 48 h), CRP, and clinical judgement guide the level of care. A score of 3 or more suggests severe disease: critical care review.
Modified Glasgow (at 48 h), CRP, and clinical judgement guide the level of care. A score of 3 or more suggests severe disease: critical care review.
↓
3
3. Nutrition
Eat as tolerated in mild disease. Enteral (NG or NJ) feeding in severe disease; avoid prolonged starvation. Parenteral only if enteral fails.
Eat as tolerated in mild disease. Enteral (NG or NJ) feeding in severe disease; avoid prolonged starvation. Parenteral only if enteral fails.
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4
4. Gallstones
ERCP within 72 h if there is concurrent cholangitis or biliary obstruction. Cholecystectomy during the same admission for mild gallstone pancreatitis once recovered.
ERCP within 72 h if there is concurrent cholangitis or biliary obstruction. Cholecystectomy during the same admission for mild gallstone pancreatitis once recovered.
| Criterion | Threshold |
|---|---|
| PaO2 | Below 8 kPa |
| Age | Over 55 years |
| Neutrophils (WCC) | Over 15 x10^9/L |
| Calcium | Below 2 mmol/L |
| Renal (urea) | Over 16 mmol/L |
| Enzymes (LDH) | Over 600 units/L |
| Albumin | Below 32 g/L |
| Sugar (glucose) | Over 10 mmol/L |
Complications
- Early: organ failure, SIRS, ARDS, AKI
- Late: necrosis, infected necrosis, pseudocyst, abscess
- Image with contrast CT at 72 h or more if not improving
Pitfalls
- Routine prophylactic antibiotics (not indicated)
- Both over- and under-resuscitation with fluids
- Missing hypocalcaemia or hypertriglyceridaemia as a cause
- Delaying critical care in persistent organ failure
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026