A 51-year-old woman presents with progressive dysphagia and weight loss. She has a history of Barrett's esophagus on surveillance. Upper endoscopy shows a stricturing lesion. What is the most appropriate next step?

Multiple biopsies of the lesion

A 48-year-old man presents with acute severe epigastric pain radiating to his back. CT shows pancreatic necrosis involving >60% of the gland. What is the most appropriate management?

Conservative management with IV fluids

Acute pancreatitis for UKMLA AKT: High-Yield Medicine (Core Systems) Lessons

Quick Overview

Acute pancreatitis is pancreatic inflammation causing severe abdominal pain with raised amylase/lipase (>3× upper limit). Gallstones (40%) and alcohol (30%) account for 70% of cases. NICE NG104 emphasizes early severity assessment, aggressive fluid resuscitation, early enteral nutrition, and timely ERCP for gallstone pancreatitis. Mortality ranges from <1% (mild) to 30% (severe necrotizing).

Core Facts & Concepts

Diagnosis (requires ≥2 of 3):

Characteristic abdominal pain (epigastric, radiating to back)
Serum lipase/amylase >3× upper limit of normal (lipase more specific)
Characteristic imaging findings (CT/MRI/USS)

Figure 1: CT abdomen showing diffuse pancreatic enlargement with peripancreatic fat stranding

Severity Assessment (NICE NG104):

Glasgow score (≥3 = severe) or APACHE II within 24 hours
CRP >150 mg/L at 48-72 hours predicts severe disease
Persistent organ failure >48 hours = severe pancreatitis

Glasgow Score (≥3 severe)	Values
PaO₂	<8 kPa
Age	>55 years
Neutrophils	>15 × 10⁹/L
Calcium	<2 mmol/L
Renal (urea)	>16 mmol/L
Enzymes (LDH/AST)	LDH >600 IU/L, AST >200 IU/L
Albumin	<32 g/L
Sugar (glucose)	>10 mmol/L

📌 Remember: PANCREAS - PaO₂, Age, Neutrophils, Calcium, Renal, Enzymes, Albumin, Sugar

Aetiology (I GET SMASHED):

Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/malignancy, Autoimmune, Scorpion venom, Hyperlipidaemia/Hypercalcaemia, ERCP, Drugs (azathioprine, sodium valproate)

Problem-Solving Approach

Initial Management (first 24 hours):

Fluid resuscitation (NICE NG104): Ringer's lactate preferred over 0.9% saline
- Target urine output ≥0.5 mL/kg/hour
- Aim for 2.5-4 L in first 24 hours (individualized)
Early enteral nutrition: Start within 72 hours via oral/NG route (reduces infection/mortality vs parenteral)
Analgesia: Opioids (morphine/fentanyl) appropriate; no evidence NSAIDs superior
ERCP timing for gallstone pancreatitis:
- Within 72 hours if concurrent cholangitis/biliary obstruction
- NOT routinely indicated for predicted mild gallstone pancreatitis without cholangitis
Antibiotics: NOT prophylactic; only for confirmed infected necrosis (FNA/clinical deterioration + gas on CT)

Figure 2: CT showing pancreatic necrosis with gas bubbles indicating infected necrosis

🚩 Red Flags:

Persistent organ failure >48 hours (respiratory/renal/cardiovascular)
Rising CRP after 48-72 hours
Clinical deterioration after initial improvement (suspect infected necrosis)

Analysis Framework

Severity Stratification:

Feature	Mild	Moderate	Severe
Organ failure	None	Transient (<48h)	Persistent (>48h)
Local complications	None	Sterile necrosis/collections	Infected necrosis
Mortality	<1%	~3-5%	20-30%
Hospital stay	5-7 days	7-14 days	Weeks-months

Infected vs Sterile Necrosis:

Clinical: fever, rising inflammatory markers after week 1
CT signs: Gas bubbles within necrotic tissue (pathognomonic)
Confirmation: FNA for culture (if intervention planned)
Management: Antibiotics + delayed necrosectomy (≥4 weeks if stable)

Visual Aid

Key Investigations Timeline:

Investigation	Timing	Purpose
Lipase/amylase	Admission	Diagnosis (>3× ULN)
USS abdomen	Within 24h	Identify gallstones
CRP	48-72h	Severity prediction (>150 mg/L)
CT abdomen	Day 6-10	Assess necrosis if severe/deteriorating

Key Points Summary

✓ Diagnosis: ≥2 of pain + lipase >3× ULN + imaging; lipase more specific than amylase

✓ Severity: Glasgow ≥3 or persistent organ failure >48h = severe; CRP >150 mg/L at 48-72h predicts severity

✓ Fluids: Ringer's lactate preferred; target 2.5-4 L first 24h with urine output ≥0.5 mL/kg/h (NICE NG104)

✓ Nutrition: Early enteral feeding within 72h reduces complications; oral/NG preferred over parenteral

✓ ERCP: Only within 72h if gallstone pancreatitis + cholangitis/obstruction; NOT routine for mild cases

✓ Antibiotics: Only for confirmed infected necrosis (gas on CT/positive FNA); NO prophylactic use

✓ Gallstone pancreatitis: Cholecystectomy during same admission (or within 2 weeks) to prevent recurrence

⚠️ Warning: Persistent organ failure >48h defines severe pancreatitis regardless of other scores

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