Pancreatitis severity and treatment

Glasgow-Imrie Prognostic Scoring System

Evaluated at 48 hours following admission to predict severe pancreatitis (mnemonic: PANCREAS):

• P: Clinical Feature: PaO2 (arterial oxygen tension); Cut-off Value: $< 8.0\text{ kPa}$ ($< 60\text{ mmHg}$) on room air

• A: Clinical Feature: Age; Cut-off Value: $> 55\text{ years}$

• N: Clinical Feature: Neutrophils (White cell count); Cut-off Value: $> 15 \times 10^9\text{/L}$

• C: Clinical Feature: Calcium (serum calcium corrected); Cut-off Value: $< 2.0\text{ mmol/L}$

• R: Clinical Feature: Renal (serum urea); Cut-off Value: $> 16.0\text{ mmol/L}$

• E: Clinical Feature: Enzymes (serum LDH); Cut-off Value: $> 600\text{ U/L}$

• A: Clinical Feature: Albumin (serum albumin); Cut-off Value: $< 32\text{ g/L}$

• S: Clinical Feature: Sugar (blood glucose); Cut-off Value: $> 10.0\text{ mmol/L}$ (in non-diabetics)

• Pancreatitis severity: Glasgow–Imrie of at least 3 predicts a higher risk of severe illness; it does not itself define severe pancreatitis or automatically mandate ICU. Revised Atlanta severity depends on organ failure (persistent beyond 48 hours for severe disease) and local/systemic complications. Follow physiology and reassess.

Evidence-Based Pancreatitis Management

1. Goal-Directed Balanced Crystalloid Resuscitation:
   • Splanchnic microcirculatory perfusion fails early due to capillary leak. Infuse balanced isotonic crystalloids (Hartmann solution or Plasmalyte are preferred over 0.9% normal saline, as large volumes of saline cause hyperchloraemic metabolic acidosis and trigger pancreatic inflammation).
   • Fluids: Use moderate goal-directed crystalloid, an initial bolus for hypovolaemia and frequent reassessment. Regimens around 1.5 mL/kg/h can guide initial treatment but are not prescriptions for everyone. Monitor perfusion, urine output and overload; routine aggressive resuscitation can cause harm.
2. Multimodal Analgesia: High-potency intravenous opioids (fentanyl, hydromorphone, or morphine) titrated intravenously alongside regular paracetamol to maintain patient comfort.
3. Early Enteral Nutrition (Abandoning Prolonged Fasting):
   • Historical practice mandated prolonged 'pancreatic rest' (NBM until pain fully resolved). Modern clinical guidelines recommend early oral feeding with a low-fat solid or liquid diet as soon as abdominal pain improves and ileus resolves (typically within 24 hours in mild pancreatitis).
   • In severe pancreatitis where oral intake is not tolerated, early enteral tube feeding (via nasogastric or nasojejunal tube) initiated within 48 hours is vastly superior to Total Parenteral Nutrition (TPN). Enteral feeding maintains gut mucosal architecture, prevents bacterial translocation across the ischaemic gut barrier, and halves the incidence of infected pancreatic necrosis and systemic sepsis.
4. Antimicrobial Stewardship: No Prophylactic Antibiotics:
   • Prophylactic intravenous antibiotics are strictly NOT recommended in acute pancreatitis, regardless of severity or the presence of sterile necrosis. Placebo-controlled trials demonstrate that prophylactic antibiotics do not reduce mortality or infected necrosis, but encourage colonization by multidrug-resistant bacteria and fungal organisms.

• Infected necrosis: Gas supports infection but may be absent. Clinical deterioration and evidence of infection warrant antibiotics and specialist assessment; a mandatory needle aspirate is not needed in every case. Drainage or debridement timing follows a multidisciplinary step-up approach, ideally allowing organisation when the patient can safely wait.

1. Indications for ERCP in Gallstone Pancreatitis:
   • Definite Indication: Concurrent acute ascending cholangitis or persistent common bile duct obstruction (worsening jaundice). ERCP with sphincterotomy must be performed within 24 hours.
   • Contraindication: Routine early ERCP is NOT indicated in gallstone pancreatitis in the absence of cholangitis or objective biliary obstruction, as it does not improve outcomes and may exacerbate pancreatitis.
2. Timing of Cholecystectomy for Gallstone Pancreatitis:
   • In mild gallstone pancreatitis, laparoscopic cholecystectomy must be performed during the INDEX hospital admission (before discharge). Delaying cholecystectomy exposes patients to an unacceptable 25% to 30% risk of recurrent biliary complications (recurrent pancreatitis, cholecystitis, or cholangitis) within 6 to 12 weeks while awaiting elective surgery.
   • In severe necrotizing pancreatitis, cholecystectomy is deferred until all acute fluid collections have resolved or stabilized (typically beyond 6 weeks).

Clinical comparison: Biliary and Pancreatic Emergencies Diagnostic Matrix

• Biliary Colic: Typical Pain Duration: $1-5\text{ hours}$ (resolves $< 6\text{h}$); Temperature & Inflammatory Markers: Normal temp; normal WCC and CRP; Serum Bilirubin & LFTs: Completely normal; Diagnostic Ultrasound / CT Findings: Cholelithiasis; normal gallbladder wall; non-dilated CBD; Definitive Procedural / Surgical Intervention: Elective outpatient laparoscopic cholecystectomy
• Choledocholithiasis: Typical Pain Duration: Variable episodic or constant colic; Temperature & Inflammatory Markers: Normal unless infected; Serum Bilirubin & LFTs: Elevated total bilirubin, marked rise in ALP & GGT; Diagnostic Ultrasound / CT Findings: Dilated CBD ($> 6\text{ mm}$); visible calculus on US, MRCP, or EUS; Definitive Procedural / Surgical Intervention: Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, followed by cholecystectomy
• Acute Ascending Cholangitis: Typical Pain Duration: Constant severe RUQ pain; Temperature & Inflammatory Markers: High spiking fevers with rigors (Charcot triad); shock (Reynolds pentad); Serum Bilirubin & LFTs: Marked obstructive jaundice, elevated ALP/GGT, hyperlactataemia; Diagnostic Ultrasound / CT Findings: Obstructed dilated CBD with calculus or stricture; Definitive Procedural / Surgical Intervention: Immediate resuscitation, IV broad-spectrum antibiotics, emergency ERCP decompression within 12-24h
• Acute Pancreatitis: Typical Pain Duration: Constant severe epigastric pain radiating to back; Temperature & Inflammatory Markers: Variable fever; leukocytosis; elevated CRP; Serum Bilirubin & LFTs: Normal (unless gallstone aetiology with concurrent duct stone); Diagnostic Ultrasound / CT Findings: Lipase $\ge 3\times\text{ULN}$; US for gallstones; CT after 72h for necrotizing pancreatitis; Definitive Procedural / Surgical Intervention: Goal-directed crystalloids, early oral nutrition, avoiding prophylactic antibiotics; index cholecystectomy

Primary references (checked 7 October 2026): ASGE cholangitis guidance.