Clinical Commander

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gi.acute-pancreatitis.core.v1

Acute Pancreatitis

gastroenterologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is full and current (ACG 2024 + IAP/APA 2025 + Revised Atlanta 2012 + WATERFALL + PONCHO + ESCAPE + AGA 2018) with 10 phenotypes, calculator wiring (BISAP, APACHE-II, SOFA, qSOFA, corrected calcium, CKD-EPI, BMI) and full medications/dosing. Problem-package at src/lib/tier3/problem-package/packages/acute-pancreatitis/ has all atoms + phenotypes + regimen + interlinks; no `_design-brief.md`. Gaps for PRODUCTION: evidence.pmids array empty (manifest cites guideline labels but no numeric PMIDs); no engine-specific test_files; no design brief md file; ICD-10 list in manifest is sparse (K86.x — pancreatitis-specific K85.x codes belong but are not authored). No regimen_axes — manifest.medications has full LR fluid, analgesics, meropenem/imipenem/pip-tazo for infected necrosis, insulin for HTG, indomethacin for PEP prophylaxis, fenofibrate, thiamine without RxCUI verification through regimen-builder.

Entry points (3)

  • symptom
    Epigastric pain radiating to back — Revised Atlanta 2012 diagnostic criterion 1 of 3
    epigastric_pain_radiating_to_back
  • lab_abnormality
    Lipase >3× upper limit of normal — Revised Atlanta 2012 + ACG 2024 Tenner diagnostic criterion
    lipase_3x_uln
  • imaging
    CT/MRI showing pancreatic inflammation/necrosis — Revised Atlanta 2012 diagnostic criterion 3 of 3
    pancreas_inflammation_ct

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    BISAP age >60 component — Wu 2008; severity prediction — ACG 2024 Tenner
  • sbprequired
    vital • used at CONTEXT
    SBP <90 with fluids defines persistent organ failure — Revised Atlanta 2012; ACG 2024 Tenner
  • hrrequired
    vital • used at CONTEXT
    SIRS criterion — Revised Atlanta 2012; hemoconcentration / shock screen — ACG 2024 Tenner
  • rrrequired
    vital • used at CONTEXT
    BISAP component — Wu 2008; respiratory failure PaO2/FiO2 <300 → severe — Revised Atlanta 2012
  • temperaturerequired
    vital • used at CONTEXT
    SIRS criterion — Revised Atlanta 2012; infected necrosis screen — ACG 2024 Tenner
  • lipaserequired
    lab • used at INITIAL_WORKUP
    ≥3× ULN diagnostic per Revised Atlanta + ACG 2024
  • bunrequired
    lab • used at INITIAL_WORKUP
    BISAP component — Wu 2008; hemoconcentration / poor prognosis marker — ACG 2024 Tenner
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Renal organ failure Cr >1.9 → severe — Revised Atlanta 2012; fluid balance — ACG 2024 Tenner
  • calciumrequired
    lab • used at INITIAL_WORKUP
    Hypocalcemia severity marker — ACG 2024 Tenner; corrected for albumin
  • hematocritrequired
    lab • used at INITIAL_WORKUP
    Hemoconcentration marker — ACG 2024 Tenner; WATERFALL fluid management — de-Madaria NEJM 2022
  • triglyceridesrequired
    lab • used at INITIAL_WORKUP
    TG >1000 → HTG-induced AP — ACG 2024 Tenner
  • altrequired
    lab • used at INITIAL_WORKUP
    ALT >150 → biliary etiology LR+ 13.3 — ACG 2024 Tenner
  • crp
    lab • used at MONITORING
    CRP >150 at 48h → severe course — ACG 2024 Tenner; AGA 2018
  • ruq_usrequired
    imaging • used at INITIAL_WORKUP
    Gallstones / sludge → biliary etiology — ACG 2024 Tenner
  • cect_pancreas
    imaging • used at BRANCHING_WORKUP
    CECT 72-96h for necrosis / local complications — ACG 2024 Tenner; AGA 2018
  • alcohol_userequired
    history • used at CONTEXT
    Alcoholic AP — second most common etiology — ACG 2024 Tenner
  • recent_ercp
    history • used at CONTEXT
    Post-ERCP pancreatitis pathway — ACG 2024 Tenner; ESGE 2020
  • recurrent_episodes
    history • used at CONTEXT
    Recurrent AP triggers etiology workup — ACG 2024 Tenner

12-phase flow (12)

  1. 1FRAME
    Confirm acute pancreatitis (2 of 3: pain + lipase ≥3× ULN + imaging) per Revised Atlanta
    inputs: lipase
    advance: AP confirmed
  2. 2ENTRY
    Recognize epigastric pain radiating to back, vomiting, or lipase elevation — Revised Atlanta 2012 presentation criteria
    advance: one entry trigger present
  3. 3CONTEXT
    Vitals, alcohol/medication history, biliary disease history, prior episodes, ERCP — ACG 2024 Tenner etiology workup
    inputs: sbp, hr, rr, temperature, alcohol_use, recent_ercp, recurrent_episodes
    advance: context captured
  4. 4RED_FLAGS
    Organ failure cv/resp/renal — Revised Atlanta 2012; abdominal compartment syndrome — ACG 2024 Tenner; infected necrosis sepsis — van Santvoort NEJM 2010 STEP-UP; severe hypocalcemia; GI hemorrhage
    inputs: sbp, creatinine
    actions: calc.qsofa
    advance: organ failure identified or excluded
  5. 5INITIAL_WORKUP
    Lipase, CBC, CMP, LFTs, TG, calcium, lactate, RUQ ultrasound, CXR/ABG if respiratory distress — ACG 2024 Tenner initial workup battery
    inputs: lipase, bun, creatinine, calcium, hematocrit, triglycerides, alt, ruq_us
    actions: panel.pancreas, panel.lft, panel.renal, panel.cbc
    advance: baseline labs + RUQ US returned
  6. 6BRANCHING_WORKUP
    CECT at 72-96h if no improvement — ACG 2024 Tenner; AGA 2018; MRCP for occult CBD stones — ESGE 2020; EUS for recurrent AP etiology; IgG4 if autoimmune suspected — ACG 2024 Tenner
    inputs: cect_pancreas
    actions: pancreatitis_severity
    advance: phenotype identified (mild / mod-severe / severe / biliary / alcoholic / HTG / drug / post-ERCP / necrotizing / recurrent)
  7. 7DIFFERENTIAL
    Distinguish from cholecystitis, choledocholithiasis/cholangitis, perforated PUD, mesenteric ischemia, inferior MI, AAA, DKA — ACG 2024 Tenner differential diagnosis
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Revised Atlanta 2012 severity (mild / moderately severe / severe); BISAP — Wu 2008; APACHE-II; modified Marshall organ failure score — Revised Atlanta 2012; Glasgow-Imrie at 48h
    inputs: bun, creatinine
    actions: calc.bisap, calc.glasgow_imrie, calc.apache2, calc.sofa
    advance: severity assigned
  9. 9TREATMENT
    Goal-directed moderate fluids LR 1.5 mL/kg/h — de-Madaria NEJM 2022 WATERFALL; early oral feeding — ACG 2024 Tenner; multimodal analgesia — ACG 2024 Tenner; ERCP within 24h if cholangitis — ESGE 2020; same-admission cholecystectomy — PONCHO da Costa Lancet 2015
    inputs: creatinine
    advance: fluids + analgesia + etiology-specific plan in motion
  10. 10DISPOSITION
    ICU for severe / necrotizing / hypotension — Revised Atlanta 2012; step-down for moderately severe; floor for mild — ACG 2024 Tenner
    inputs: sbp
    advance: destination set
  11. 11MONITORING
    Vitals q4-8h first 48h — ACG 2024 Tenner; BUN/Cr/Hct at 24h+48h — ACG 2024 Tenner; CRP at 48h — AGA 2018; hourly UOP if severe — de-Madaria NEJM 2022 WATERFALL; SOFA daily for severe — Revised Atlanta 2012
    inputs: bun, creatinine, hematocrit, crp
    advance: response documented or escalated
  12. 12FOLLOWUP
    GI follow-up 2-4 weeks — ACG 2024 Tenner; cholecystectomy timing for biliary — PONCHO da Costa Lancet 2015; alcohol/TG control — ACG 2024 Tenner; EPI screen post-necrotizing; recurrence workup if ≥2 episodes — ACG 2024 Tenner
    advance: follow-up scheduled