| Letter | Cause | % of Cases |
|---|---|---|
| I | Idiopathic | ~10โ15% |
| G | Gallstones | ~40% (most common) |
| E | Ethanol | ~30% (2nd most common) |
| T | Trauma / tumor | ~2โ5% |
| S | Steroids / scorpion stings | Rare |
| M | Mumps / autoimmune | Rare |
| A | Autoimmune (IgG4) | ~2% |
| S | Sphincter of Oddi dysfunction | Rare |
| H | Hyperlipidemia / Hypercalcemia / Hypothermia | TG > 1000 โ ~5% |
| E | ERCP | ~5% post-ERCP |
| D | Drugs (azathioprine, valproic acid, didanosine, mesalamine) | ~2% |
| Severity | Definition | Mortality |
|---|---|---|
| Mild (~80%) | No organ failure, no local complications | < 1% |
| Moderately severe (~15%) | Transient organ failure (< 48h) OR local complications (necrosis, pseudocyst, fluid collections) | ~5% |
| Severe (~5%) | Persistent organ failure > 48h (respiratory, renal, cardiovascular) | 15โ30% |
| Complication | Timing | Management |
|---|---|---|
| Acute peripancreatic fluid collection | < 4 weeks | Usually resolves spontaneously. No intervention unless infected. |
| Pancreatic pseudocyst | > 4 weeks, encapsulated | Drain if symptomatic (> 6 cm, infected, obstructing). EUS-guided drainage preferred. |
| Acute necrotic collection | < 4 weeks | Sterile โ supportive. Infected โ antibiotics + delayed drainage (wait โฅ 4 weeks if stable for walled-off necrosis to mature). |
| Walled-off necrosis (WON) | > 4 weeks, encapsulated | If infected: step-up approach -antibiotics โ percutaneous/endoscopic drainage โ surgical necrosectomy only if drainage fails PANTER, 2010. |
| Splenic vein thrombosis | Variable | Left-sided portal HTN โ isolated gastric varices. Anticoagulation if symptomatic. Splenectomy if refractory GI bleeding. |
Patient: 52M heavy drinker, epigastric pain radiating to back ร 12h, lipase 2,400 (>3ร ULN), HR 105, Cr 1.8.
Initial management:
Severity assessment at 48h:
Complications to watch: Necrotizing pancreatitis (infected necrosis โ antibiotics + drainage), pseudocyst (>4 weeks), pancreatic abscess. Infected necrosis = carbapenems + IR/surgical drainage.
| Drug | Dose | Route | Notes |
|---|---|---|---|
| LR | 1.5mL/kg/hr | IV | Goal-directed hydration |
| Hydromorphone | 0.5-1mg q3-4h | IV | Multimodal pain |
| Ketorolac | 15-30mg q6hร5d | IV | NSAID adjunct |
| No prophylactic abx | - | - | Unless infected necrosis |
Patient: 52 y/o F with cholelithiasis, presents with severe epigastric pain radiating to the back, fever 39.4ยฐC, and jaundice.
Key findings: HR 118, BP 96/58. Lipase 5,200, total bilirubin 6.8, direct 5.2, ALP 420, WBC 19K. RUQ US: gallstones, CBD dilated to 11 mm.
Management:
Teaching point: Cholangitis requires urgent ERCP (within 24h), do not waste time with MRCP when Charcot's triad is present. Use MRCP only when choledocholithiasis is suspected but the patient is stable and not cholangitic.
Patient: 38 y/o M with poorly controlled DM2 and obesity, presents with severe epigastric pain. No alcohol use, no gallstones.
Key findings: Lipase 3,800, triglycerides 4,200 mg/dL, glucose 380, HbA1c 12.4%. Lipemic serum. CT: peripancreatic stranding without necrosis.
Management:
Teaching point: TG-induced pancreatitis (TG > 1,000) requires insulin drip for rapid TG clearance. Unlike gallstone pancreatitis, keep strictly NPO until TGs are controlled. Consider plasmapheresis if TG > 5,000 or refractory to insulin.
Patient: 60 y/o M with alcohol-induced pancreatitis, initially improving then develops new fever and leukocytosis at day 10.
Key findings: CT abdomen: 40% pancreatic necrosis with gas bubbles in the necrotic collection. WBC 24K (was trending down), fever 38.8ยฐC, procalcitonin rising.
Management:
Teaching point: Prophylactic antibiotics for sterile necrotizing pancreatitis have no benefit. Antibiotics are indicated ONLY for infected necrosis (suspect at day 7-10+ if clinical worsening). The step-up approach (drain first, surgery only if needed) is superior to early surgery.