Acute Pancreatitis in 2025

Let’s chat about the pancreas, and specifically acute pancreatitis.

Question: ​ What do the guidelines say about acute pancreatitis management?

• See the 2024 American College of Gastroenterology Guidelines for more details as the guidelines are comprehensive.

• Recall the diagnostic criteria: Identification of 2 of the 3 criteria: characteristic abdominal pain (epigastric/LUQ abdominal pain), serum amylase/lipase 3x the upper limit of normal, and imaging findings consistent with pancreatitis.

  • Routine use of CTAP for diagnosis or severity determination is not warranted as the diagnosis is often apparent based on their abdominal pain and laboratory studies.

  • If a patient has epigastric pain and a lipase 3x ULN, they have acute pancreatitis!

• Etiology:

  • Think gallstones (40-70%) and alcohol (25-35%). Get that RUQ US, as gallstone pancreatitis should 100% be admitted with plan for cholecystectomy before discharge. If these aren’t the causes, check a triglyceride level (TG >1000 mg/dL is consistent with TG-associated pancreatitis). Don’t forget hypercalcemia.

  • New evidence suggests that tiny microliths or sludge can cause recurrent pancreatitis—so if a patient keeps having pancreatitis with no identifiable cause, the ACG now recommends cholecystectomy.

• Risk Assessment:

  • Most episodes of acute pancreatitis are mild and self-limiting, needing only a brief hospitalization. However, 20% of these mild cases will develop moderately severe or severe disease.

  • These guidelines note that most patients who develop a complicated course initially present to the ED appearing to have mild disease, without organ failure or necrosis.

  • Unfortunately, a substantial proportion of patients cannot be reliably classified as mild, moderate, or severe during the first 24-48 hours.

  • Scoring systems and imaging alone are not accurate in predicting which patients will develop severe disease.

  • BUN and hematocrit elevation are risk factors for severe disease.

  • Severe pancreatitis can look like sepsis—with SIRS criteria and multiorgan failure.

• Treatment:

  • IVF hydration is key in acute pancreatitis. The preferred fluid is LR. A recent multi-center RCT (WATERFALL), demonstrated that moderate fluid resuscitation is as effective as early aggressive hydration.

  • If hypovolemic from significant volume losses, consider a 10cc/kg bolus and then initiate IVF hydration at ~1.5cc/kg/hr. You can skip the bolus if they look euvolemic.

• Nutrition

  • We have moved away from the NPO “gut-rest” paradigm to an early PO paradigm—enteral nutrition maintains gut integrity.

  • In mild pancreatitis, we can start with a low-residue, low-fat, soft diet. In severe pancreatitis, early enteral nutrition with a NGT seems to prevent infectious complications.

• Surgery

  • Those patients with mild acute gallstone pancreatitis should undergo early cholecystectomy, ideally before discharge

Question: What do emergency medicine doctors have to say about this?

• See this 2025 review article or an older, 2018 review from JEM.

• They affirm the diagnosis is primarily driven by symptoms and lipase and treatment cornerstones include moderate fluid resuscitation and early oral feeding.

• What about disposition?

  • Decision regarding hospitalization or outpatient management is mainly guided by oral tolerance, severity of abdominal pain, and suspected etiology.

  • Patients who can tolerate oral intake, have manageable pain, and have a suspected etiology that does not require immediate intervention in the ED may be considered for ED discharge. Mild cases due to alcohol, post-ERCP, or medications may often be appropriate for ED discharge or for observation admission.

  • Admit patients with abnormal vital signs, abnormal BUN, evidence of organ insufficiency, comorbidities, refractory pain despite IV analgesia, inability to tolerate PO, persistent nausea, gallstone pancreatitis, TG-associated pancreatitis, and likely poor outpatient follow-up.

  • Remember that it can be hard to predict who will go on to develop severe disease—guaranteed follow-up and strict return precautions are necessary before discharge.

Cheers,

Dillon

Resources Cited:

1. de-Madaria, E., Buxbaum, J. L., Maisonneuve, P., García García de Paredes, A., Zapater, P., Guilabert, L., Vaillo-Rocamora, A., Rodríguez-Gandía, M. Á., Donate-Ortega, J., Lozada-Hernández, E. E., Collazo Moreno, A. J. R., Lira-Aguilar, A., Llovet, L. P., Mehta, R., Tandel, R., Navarro, P., Sánchez-Pardo, A. M., Sánchez-Marin, C., Cobreros, M., Fernández-Cabrera, I., … ERICA Consortium (2022). Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis. The New England journal of medicine, 387(11), 989–1000. [pubmed]

2. Waller, A., Long, B., Koyfman, A., & Gottlieb, M. (2018). Acute Pancreatitis: Updates for Emergency Clinicians. The Journal of emergency medicine, 55(6), 769–779. [pubmed]

3. Tenner, S., Vege, S. S., Sheth, S. G., Sauer, B., Yang, A., Conwell, D. L., Yadlapati, R. H., & Gardner, T. B. (2024). American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. The American journal of gastroenterology, 119(3), 419–437.[pubmed]

4. Hawatian K, Sidani M, Hagerman T, Condon S, Chien C, Miller J. Contemporary Approach to Acute Pancreatitis in Emergency Medicine. J Am Coll Emerg Physicians Open. 2025;6(2):100063. Published 2025 Feb 18. [pubmed]