🔥 Chapter 76: Severe Acute Pancreatitis

BISAP Score · Atlanta Criteria · CT Severity Index · Fluid Resuscitation · Enteral Nutrition · Pancreatic Necrosis · ERCP

🔥 Severe Acute Pancreatitis: Organ Failure + Local Complications

📊 Diagnostic Criteria (2 of 3)
1. Abdominal pain (epigastric radiating to back)
2. Serum lipase/amylase ≥3x upper limit of normal
3. Imaging findings (CT/MRI/US) of pancreatitis
📋 Severity Scores
• BISAP score (≥3 = increased risk): BUN >25, Impaired mental status, SIRS, Age >60, Pleural effusion
• Atlanta Criteria: organ failure + local complications
• CT Severity Index >6 = severe
• Persistent organ failure >48h = severe
🩸 Aetiology in Children
• Biliary (gallstones, sludge)
• Drug-induced (valproate, L-asparaginase, steroids, 6-MP)
• Trauma
• Infections (mumps, coxsackie, hepatitis)
• Metabolic (DKA, hypertriglyceridaemia)
• Hereditary (CFTR, SPINK1, PRSS1)
💧 Resuscitation (Key)
• Aggressive IV fluids (crystalloids)
• Target UOP >0.5-1 mL/kg/h
• Avoid fluid overload — monitor for pulmonary oedema, ACS
• Invasive haemodynamic monitoring if shock
🍽️ Nutrition
• Early enteral feeding (nasojejunal) within 24-48h — better than parenteral
• Reduces infectious complications, length of stay
• Bowel rest only if vomiting/ileus
⚠️ Complications
• Pancreatic necrosis (infected → high mortality)
• Pseudocyst, abscess
• Abdominal compartment syndrome
• Multi-organ failure (respiratory, renal, shock)
📌 Key Pearls: No role for prophylactic antibiotics. Early enteral nutrition (within 24-48h) reduces mortality. Fluid resuscitation is critical. ERCP only for cholangitis or persistent biliary obstruction.

🩺 Step-by-Step: Severe Acute Pancreatitis Management

1
Diagnosis — confirm pancreatitis
Abdominal pain + lipase/amylase ≥3x ULN +/or imaging. Rule out other causes of acute abdomen. Obtain baseline labs: CBC, CMP, LFTs, lipase, calcium, triglycerides, glucose.
2
Risk stratification — identify severe pancreatitis
Calculate BISAP score within 24h. Assess for organ failure (respiratory, renal, cardiovascular). CT scan not needed for diagnosis if diagnosis clear — reserve for complications or uncertain diagnosis.
3
Aggressive fluid resuscitation
IV crystalloids (NS or LR) at 10-20 mL/kg bolus followed by 1.5-2x maintenance. Target UOP >0.5 mL/kg/h. Monitor for fluid overload (pulmonary oedema, oxygen requirement). Invasive monitoring if shock.
4
Pain management
Morphine or fentanyl IV (morphine does NOT worsen pancreatitis — old myth). Patient-controlled analgesia if available. Avoid meperidine (seizure risk with repeated dosing).
5
Nutrition — early enteral feeding
Start nasojejunal enteral nutrition within 24-48h (better than TPN). If vomiting/ileus, NG decompression. If enteral not tolerated, TPN.
6
No routine antibiotics
Prophylactic antibiotics NOT indicated for sterile necrosis. Antibiotics only for suspected infected necrosis (fever, leucocytosis after first week, gas on CT). Use carbapenem or 3rd gen cephalosporin + metronidazole.
7
ERCP indications
• Acute cholangitis
• Persistent biliary obstruction
• Gallstone pancreatitis with worsening LFTs
NOT indicated for all gallstone pancreatitis.
8
Monitor for complications
• Pancreatic necrosis (CT with contrast after 48-72h)
• Pseudocyst — usually resolves spontaneously
• Infected necrosis → drainage (percutaneous or endoscopic necrosectomy)
• Abdominal compartment syndrome → decompression