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gi.acute-pancreatitis.core.v1PRODUCTION
gi.acute-pancreatitis.core.v1

Acute Pancreatitis

gastroenterologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute pancreatitis (2 of 3: pain + lipase ≥3× ULN + imaging) per Revised Atlanta

Inputs
1
Actions
0
Advance rule
Set
Advance when

AP confirmed

Patient inputs (18)

BISAP age >60 component — Wu 2008; severity prediction — ACG 2024 Tenner

SBP <90 with fluids defines persistent organ failure — Revised Atlanta 2012; ACG 2024 Tenner

SIRS criterion — Revised Atlanta 2012; hemoconcentration / shock screen — ACG 2024 Tenner

BISAP component — Wu 2008; respiratory failure PaO2/FiO2 <300 → severe — Revised Atlanta 2012

SIRS criterion — Revised Atlanta 2012; infected necrosis screen — ACG 2024 Tenner

Alcoholic AP — second most common etiology — ACG 2024 Tenner

≥3× ULN diagnostic per Revised Atlanta + ACG 2024

BISAP component — Wu 2008; hemoconcentration / poor prognosis marker — ACG 2024 Tenner

Renal organ failure Cr >1.9 → severe — Revised Atlanta 2012; fluid balance — ACG 2024 Tenner

Hypocalcemia severity marker — ACG 2024 Tenner; corrected for albumin

Hemoconcentration marker — ACG 2024 Tenner; WATERFALL fluid management — de-Madaria NEJM 2022

TG >1000 → HTG-induced AP — ACG 2024 Tenner

ALT >150 → biliary etiology LR+ 13.3 — ACG 2024 Tenner

Gallstones / sludge → biliary etiology — ACG 2024 Tenner

CECT 72-96h for necrosis / local complications — ACG 2024 Tenner; AGA 2018

Post-ERCP pancreatitis pathway — ACG 2024 Tenner; ESGE 2020

Recurrent AP triggers etiology workup — ACG 2024 Tenner

CRP >150 at 48h → severe course — ACG 2024 Tenner; AGA 2018

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningpersistent organ failure >48h — Revised Atlanta 2012
    Modified Marshall organ failure score in any organ system persisting >48h (Revised Atlanta 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninginfected_pancreatic_necrosis
    Sepsis + gas in necrotic collection on CT OR positive FNA culture (ACG 2024 Tenner; van Santvoort NEJM 2010 STEP-UP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningabdominal_compartment_syndrome
    IAP >20 mmHg + new organ dysfunction (ACG 2024 Tenner)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebisap ge 3 — Wu 2008
    BISAP score >=3 within 24h of presentation (Wu 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecholangitis overlap — ACG 2024
    Charcot/Reynolds pentad in biliary AP (ACG 2024 Tenner; ESGE 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateHTG induced AP TG >1000 — ACG 2024
    TG >1000 mg/dL in AP (ACG 2024 Tenner)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbiliary_AP_mild_PONCHO
    Mild biliary AP — gallstones on US, resolved AP (PONCHO da Costa Lancet 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Acute pancreatitis severity-driven regimen — ACG 2024 + WATERFALL fluid + IAP/APA 2025
axis: acute_pancreatitis_severity_pathwaystep 1 - Step 1 — Mild AP (Revised Atlanta 2012 mild — no organ failure)
Selected step "Step 1 — Mild AP (Revised Atlanta 2012 mild — no organ failure)" — Lipase ≥3× ULN + characteristic pain — Revised Atlanta 2012; no organ failure; BISAP <3 — Wu 2008
  • lactated_ringers
    first line
    crystalloid_balanced
    WATERFALL — 1.5 mL/kg/h continuous (moderate); 10 mL/kg bolus only if hypovolemic (avoid aggressive 5-10 mL/kg/h based on WATERFALL 2022 NEJM) • IV • continuous
    triggers: acute_pancreatitis — Revised Atlanta 2012
    WATERFALL de-Madaria NEJM 2022 — moderate fluids reduce fluid overload morbidity vs aggressive; LR preferred over NS (ACG 2013 Tenner)
  • hydromorphone
    first line
    opioid
    0.5-1 mg IV q3-4h PRN • IV • q3-4h PRN
    triggers: moderate_severe_pain — ACG 2024 Tenner
    Multimodal — ACG 2024 Tenner prefers hydromorphone over morphine; morphine acceptable (no clinical evidence of sphincter of Oddi spasm)
    rxcui 3423
  • acetaminophen
    first line
    analgesic
    1 g IV/PO q6h max 4 g/day • IV/PO • q6h
    triggers: mild_moderate_pain — ACG 2024 Tenner, opioid_sparing — ACG 2024 Tenner
    Multimodal pain control adjunct — ACG 2024 Tenner
    rxcui 161
  • ondansetron
    first line
    antiemetic_5HT3
    4 mg IV/PO q6h PRN • IV/PO • q6h PRN
    triggers: nausea_vomiting — ACG 2024 Tenner
    Symptom control — ACG 2024 Tenner
    rxcui 26225

ed playbook — drug actions (5)

  1. 1. lactated Ringers (moderate)
    10 mL/kg bolus only if hypovolemic; otherwise 1.5 mL/kg/h continuous • IV • continuous
    trigger: AP confirmed — Revised Atlanta 2012
    WATERFALL de-Madaria NEJM 2022 — moderate goal-directed; avoid aggressive >5 mL/kg/h
  2. 2. hydromorphone
    0.5-1 mg IV q3-4h PRN • IV • PRN
    trigger: Moderate-severe pain — ACG 2024 Tenner
    Multimodal analgesia — ACG 2024 Tenner
  3. 3. acetaminophen
    1 g IV/PO q6h • IV/PO • q6h
    trigger: Pain opioid-sparing — ACG 2024 Tenner
    Multimodal analgesia adjunct — ACG 2024 Tenner
  4. 4. ondansetron
    4 mg IV q6h PRN • IV • PRN
    trigger: Nausea/vomiting — ACG 2024 Tenner
    Symptom control — ACG 2024 Tenner
  5. 5. pip-tazo if cholangitis overlap
    4.5 g IV q6h • IV • q6h
    trigger: Concurrent cholangitis — ACG 2024 Tenner; ESGE 2020
    Empiric biliary sepsis coverage; ERCP within 24h — ACG 2024 Tenner; ESGE 2020

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Epigastric pain radiating to back — Revised Atlanta 2012 diagnostic criterion 1 of 3; Lipase >3× upper limit of normal — Revised Atlanta 2012 + ACG 2024 Tenner diagnostic criterion; CT/MRI showing pancreatic inflammation/necrosis — Revised Atlanta 2012 diagnostic criterion 3 of 3.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Pancreatitis** (gi.acute-pancreatitis.core.v1).
Phenotype framing: Distinguish from cholecystitis, choledocholithiasis/cholangitis, perforated PUD, mesenteric ischemia, inferior MI, AAA, DKA — ACG 2024 Tenner differential diagnosis
Scope: Confirm acute pancreatitis (2 of 3: pain + lipase ≥3× ULN + imaging) per Revised Atlanta

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute pancreatitis severity-driven regimen — ACG 2024 + WATERFALL fluid + IAP/APA 2025** — step "Step 1 — Mild AP (Revised Atlanta 2012 mild — no organ failure)".
1. lactated_ringers WATERFALL — 1.5 mL/kg/h continuous (moderate); 10 mL/kg bolus only if hypovolemic (avoid aggressive 5-10 mL/kg/h based on WATERFALL 2022 NEJM) IV continuous (crystalloid_balanced, first line) — WATERFALL de-Madaria NEJM 2022 — moderate fluids reduce fluid overload morbidity vs aggressive; LR preferred over NS (ACG 2013 Tenner)
2. hydromorphone 0.5-1 mg IV q3-4h PRN IV q3-4h PRN (opioid, first line) — Multimodal — ACG 2024 Tenner prefers hydromorphone over morphine; morphine acceptable (no clinical evidence of sphincter of Oddi spasm)
3. acetaminophen 1 g IV/PO q6h max 4 g/day IV/PO q6h (analgesic, first line) — Multimodal pain control adjunct — ACG 2024 Tenner
4. ondansetron 4 mg IV/PO q6h PRN IV/PO q6h PRN (antiemetic_5HT3, first line) — Symptom control — ACG 2024 Tenner

Setting playbook (ed) — Confirm AP 2 of 3 — Revised Atlanta 2012; risk-stratify BISAP — Wu 2008 + organ failure screen; initiate moderate goal-directed fluids — de-Madaria NEJM 2022 WATERFALL; pain control — ACG 2024 Tenner; etiology workup; early enteral feeding — ACG 2024 Tenner
5. lactated Ringers (moderate) 10 mL/kg bolus only if hypovolemic; otherwise 1.5 mL/kg/h continuous IV continuous — AP confirmed — Revised Atlanta 2012 (WATERFALL de-Madaria NEJM 2022 — moderate goal-directed; avoid aggressive >5 mL/kg/h)
6. hydromorphone 0.5-1 mg IV q3-4h PRN IV PRN — Moderate-severe pain — ACG 2024 Tenner (Multimodal analgesia — ACG 2024 Tenner)
7. acetaminophen 1 g IV/PO q6h IV/PO q6h — Pain opioid-sparing — ACG 2024 Tenner (Multimodal analgesia adjunct — ACG 2024 Tenner)
8. ondansetron 4 mg IV q6h PRN IV PRN — Nausea/vomiting — ACG 2024 Tenner (Symptom control — ACG 2024 Tenner)
9. pip-tazo if cholangitis overlap 4.5 g IV q6h IV q6h — Concurrent cholangitis — ACG 2024 Tenner; ESGE 2020 (Empiric biliary sepsis coverage; ERCP within 24h — ACG 2024 Tenner; ESGE 2020)

Non-pharmacologic actions:
- NPO in moderate-severe; clear liquids attempted at 24-48h in mild (ACG 2024 Tenner — early oral feeding)
- NGT only for refractory vomiting (not routine) (ACG 2024 Tenner)
- Foley if hourly UOP needed in severe (de-Madaria NEJM 2022 WATERFALL)
- Daily NIH/SOFA score (Revised Atlanta 2012)
- GI consult for biliary AP / persistent CBD obstruction (ACG 2024 Tenner; ESGE 2020)

AVOID / contraindication checks:
- No_prophylactic_antibiotics_in_sterile_necrosis (ACG 2024 Tenner; AGA 2018 — no mortality benefit)
- No_aggressive_5_to_10_mL_per_kg_per_h_fluids_per_WATERFALL_safety_stop (de Madaria NEJM 2022 WATERFALL)
- Morphine_no_evidence_for_sphincter_of_Oddi_spasm_use_acceptable (ACG 2024 Tenner)
- Hold_oral_intake_only_in_severe_with_ileus_resume_when_pain_subsides (ACG 2024 Tenner — early oral feeding preferred)
- Fenofibrate_avoid_during_acute_pancreatitis_phase (ACG 2024 Tenner)

Monitoring

Regimen monitoring:
- BUN Hct q24h first 48h then PRN (ACG 2024 Tenner — hemoconcentration prognostic marker)
- CRP at 48h >150 predicts severe (ACG 2024 Tenner; AGA 2018)
- BISAP at 24h (Wu 2008; ACG 2024 Tenner)
- SOFA daily in severe (Revised Atlanta 2012 — modified Marshall organ failure)
- Hourly UOP in severe (de-Madaria NEJM 2022 WATERFALL — fluid adequacy target >=0.5 mL/kg/h)
- Daily lipase NOT useful after diagnosis (ACG 2024 Tenner)
- CECT pancreas at 72 96h if no clinical improvement (ACG 2024 Tenner; AGA 2018)
- CRP + BUN trend; check for overdistention by abdominal compartment syndrome (ACG 2024 Tenner)

Setting (ed) monitoring:
- BUN/Cr/Hct q12-24h first 48h (ACG 2024 Tenner — hemoconcentration marker)
- CRP at 48h (ACG 2024 Tenner; AGA 2018 — >150 predicts severe)
- Hourly UOP (target >=0.5 mL/kg/h) if severe (de-Madaria NEJM 2022 WATERFALL)
- SpO2 + RR (PaO2/FiO2 <300 → severe) (Revised Atlanta 2012)
- Daily abdominal exam (ACG 2024 Tenner)

Follow-up plan: 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
- Close-out criterion: follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: ed — Confirm AP 2 of 3 — Revised Atlanta 2012; risk-stratify BISAP — Wu 2008 + organ failure screen; initiate moderate goal-directed fluids — de-Madaria NEJM 2022 WATERFALL; pain control — ACG 2024 Tenner; etiology workup; early enteral feeding — ACG 2024 Tenner

Disposition criteria:
- Discharge: mild AP tolerating diet, pain controlled, no organ failure, follow-up scheduled (ACG 2024 Tenner)
- Admit ward: mild-moderate AP not yet tolerating diet (ACG 2024 Tenner)
- Admit ICU: severe AP, organ failure, BISAP >=3, infected necrosis suspected (Revised Atlanta 2012; ACG 2024 Tenner)

Escalation triggers (move to higher acuity):
- BISAP >=3 OR persistent organ failure → ICU (Wu 2008; Revised Atlanta 2012)
- Hypotension despite fluids → ICU + vasopressors (ACG 2024 Tenner)
- Cholangitis (Charcot/Reynolds) → emergent ERCP within 24h (ACG 2024 Tenner; ESGE 2020)
- Abdominal compartment syndrome (IAP >20 + organ dysfunction) → ICU + decompression consideration (ACG 2024 Tenner)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Modified Marshall organ failure score in any organ system persisting >48h (Revised Atlanta 2012)
- [LIFE_THREATENING] Sepsis + gas in necrotic collection on CT OR positive FNA culture (ACG 2024 Tenner; van Santvoort NEJM 2010 STEP-UP)
- [LIFE_THREATENING] IAP >20 mmHg + new organ dysfunction (ACG 2024 Tenner)

Citations

- ACG 2024 Acute Pancreatitis Guideline + IAP/APA Revised Guidelines 2025 + Revised Atlanta 2012 + WATERFALL (NEJM 2022) + PONCHO (Lancet 2015) + ESCAPE (Lancet 2018) [PMID:36103415](https://pubmed.ncbi.nlm.nih.gov/36103415/)
- Cited evidence (PMID 25409371) [PMID:25409371](https://pubmed.ncbi.nlm.nih.gov/25409371/)
- Cited evidence (PMID 20410514) [PMID:20410514](https://pubmed.ncbi.nlm.nih.gov/20410514/)
- Cited evidence (PMID 23896955) [PMID:23896955](https://pubmed.ncbi.nlm.nih.gov/23896955/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ACG 2024 Acute Pancreatitis Guideline + IAP/APA Revised Guidelines 2025 + Revised Atlanta 2012 + WATERFALL (NEJM 2022) + PONCHO (Lancet 2015) + ESCAPE (Lancet 2018) — PMID:36103415
  • Cited evidence (PMID 25409371) — PMID:25409371
  • Cited evidence (PMID 20410514) — PMID:20410514
  • Cited evidence (PMID 23896955) — PMID:23896955