Diagnosis and Classification

Atlanta criteria for the diagnosis of acute pancreatitis (AP), classically need 2 of 3: 1. Lipase or amylase > 3x ULN 2. Typical pain syndrome 3. Radiographic demonstration of pancreatic inflammation

Risk Stratification

• BISAP
• APACHE II
• Ranson's criteria
• SOFA

Classification

Etiologies

1. Gallstone
2. Alcohol
3. Medications
   1. DPP4 inhibitors
   2. ACE inhibitors

Management

Antibiotics

• no role for routine prophylactic antibiotics in AP.

Enteral Feeding

• evidence suggests that early enteral feeding is superior. An initial low-fat full diet at the time of diagnosis has been shown to possible reduce LOS, improve pain, and is not inferior to a standard graduated dietary approach.

Fluid Management

• historical paradigm dictates that due to inflammation, aggressive large volume fluid resuscitation is mandated for these patients
• WATERFALL (NEJM 2022) trial [@de-madariaAggressiveModerateFluid2022] demonstrates that for mild pancreatitis, a restrictive fluid resuscitation approach is non-inferior and may be better than a liberal fluid approach:
  • Outcomes:
    • reduced progression to moderate and severe pancreatitis
    • reduced iatrogenic fluid overload
  • Strategy:
    • Fluid bolus: only given initially for hypovolemia
    • Maintenance: 3 mL/kg/hr (liberal) vs 1.5 mL/kg/hr (restrictive)
    • Endpoint:

Trending Pancreatic Enzymes

• no role for routinely re-checking and trending lipase or amylase in AP

Complications

1. ARDS
2. Pancreatic pseudocyst