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Gastroenterology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Severe epigastric pain radiating to the back, vomiting; gallstones on USS; lipase 12× ULN; HR 112, RR 24
Red flags Persistent SIRS/organ failure Hypocalcaemia Necrosis on CT Cholangitis Rising intra-abdominal pressure Differential diagnosis Perforated peptic ulcer Cholangitis/cholecystitis Mesenteric ischaemia Ruptured AAA Inferior MI DKA When to admit, call ICU or discharge Admit: All acute pancreatitisICU: Persistent organ failure, severe SIRS, infected necrosis with sepsisIntubate: ARDS or respiratory failureVasopressors: Shock despite adequate fluidsDialysis: AKI with refractory acidosis, K⁺ or overloadKey points Severity is decided by organ failure, not lipase level. Recurrence after gallstone pancreatitis is ~25% within weeks if cholecystectomy is delayed. Alcohol: brief intervention and relapse prevention before discharge. Never Give prophylactic antibiotics without infected necrosis or cholangitis Do early ERCP for gallstone pancreatitis without cholangitis Continue aggressive fluids after 48 h Keep patients nil by mouth routinely Common mistakes Prophylactic antibiotics Over-resuscitation Delayed feeding Missing hypertriglyceridaemia Disposition and follow-up Ward for mild; HDU/ICU for organ failure. Cholecystectomy same admission; follow-up imaging for collections.
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