Synopsis
Confirm acute pancreatitis, recognise competing emergencies and establish a defensible cause so that immediate care and recurrence prevention follow the actual findings.
- Diagnose using two of three: characteristic pain, pancreatic enzymes above three times the laboratory upper limit, or compatible imaging.
- When typical pain and a diagnostic enzyme rise agree, CT is not required merely to provide the third criterion.
- Establish the cause with a focused history, liver tests, calcium, triglycerides and biliary ultrasound; alcohol exposure alone is insufficient attribution.
Key red flags
New hypotension, oliguria or confusion despite initial assessment and support.
Rigid abdomen, gastrointestinal bleeding or abrupt pain with cardiovascular collapse.
Fever with jaundice and biliary obstruction suggesting associated cholangitis.
Sudden maximal pain, a rigid abdomen, marked gastrointestinal bleeding or pain disproportionate to physical findings should reopen the differential. Pancreatic enzymes can rise in other intra-abdominal disease and with impaired renal clearance. Do not allow an abnormal blood test to delay investigation for perforation, intestinal ischaemia or a vascular catastrophe when the clinical pattern points there.
Investigation priorities
Test whether the biochemical and clinical criteria agree at this presentation.
Management branches
A constructed example links diagnostic certainty to an observed inpatient decision.
- A 44-year-old woman presents with 12 hours of persistent epigastric pain radiating to the back and vomiting. Lipase is 920 U/L against an upper limit of 60 U/L; examination shows epigastric tenderness without rigidity. The team diagnoses pancreatitis from pain and enzymes, starts supportive care and does not order CT simply to obtain a third criterion.
- Her ALT is 260 U/L and ultrasound shows gallbladder stones without duct dilatation. Bilirubin falls during observation; she has no fever, persistent jaundice or evidence of cholangitis. These findings support a biliary attack after stone passage. The surgical team records this causal assessment and the absence of an immediate indication for ERCP. She subsequently recovers without organ failure and undergoes uncomplicated cholecystectomy during the same admission.