A 72-year-old woman comes to the emergency department because of upper abdominal pain and nausea for the past hour. The patient rates the pain as an 8 to 9 on a 10-point scale. She has had an episode of nonbloody vomiting since the pain started. She has a history of type 2 diabetes mellitus, hypertension, and osteoporosis. The patient has smoked 2 packs of cigarettes daily for 40 years. She drinks 5–6 alcoholic beverages daily. Current medications include glyburide, lisinopril, and oral vitamin D supplements. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Ultrasonography of the abdomen shows diffuse enlargement of the pancreas; no gallstones are visualized. The patient is admitted to the hospital for pain control and intravenous hydration. Which of the following is the most appropriate next step in the management of this patient’s pain?

Patient-controlled intravenous hydromorphone

Transdermal fentanyl every 72 hours

Oral acetaminophen every 6 hours

Transdermal bupivacaine on request

A 49-year-old man comes to the emergency department because of recurrent abdominal pain for 1 week. The pain is worse after eating and he has vomited twice during this period. He was hospitalized twice for acute pancreatitis during the past year; the latest being 2 months ago. There is no family history of serious illness. His only medication is a vitamin supplement. He has a history of drinking five beers a day for several years but quit 1 month ago. His temperature is 37.1°C (98.8°F), pulse is 98/min and blood pressure 110/70 mm Hg. He appears uncomfortable. Examination shows epigastric tenderness to palpation; there is no guarding or rebound. A CT scan of the abdomen shows a 6-cm low attenuation oval collection with a well-defined wall contiguous with the body of the pancreas. Which of the following is the most appropriate next step in management?

CT-guided percutaneous drainage

Magnetic resonance cholangiopancreatography

A 58-year-old woman comes to the emergency department because of a 2-day history of worsening upper abdominal pain. She reports nausea and vomiting, and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), pulse is 92/min, respirations are 18/min, and blood pressure is 132/85 mm Hg. Examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. Laboratory studies show: Hemoglobin 13 g/dL Leukocyte count 16,000/mm3 Serum Urea nitrogen 25 mg/dL Creatinine 2 mg/dL Alkaline phosphatase 432 U/L Alanine aminotransferase 196 U/L Aspartate transaminase 207 U/L Bilirubin Total 3.8 mg/dL Direct 2.7 mg/dL Lipase 82 U/L (N = 14–280) Ultrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder. The pancreas is not well visualized. Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole is begun. Twelve hours later, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?

Endoscopic retrograde cholangiopancreatography

Extracorporeal shock wave lithotripsy

Management of acute pancreatitis for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Initial Rx - First Moves Matter

IV Fluids (Most Critical Step): Aggressive hydration is paramount.
- Solution: Lactated Ringer's is preferred; may reduce SIRS.
- Rate: Bolus of 15-20 mL/kg, then 3 mL/kg/hr (or 5-10 mL/kg/hr).
- Goal: ↓ BUN, urine output >0.5 mL/kg/hr.
Analgesia: IV opioids (e.g., hydromorphone, fentanyl) for severe pain.
NPO (Nil Per Os): Bowel rest to limit pancreatic stimulation.

⭐ Prophylactic antibiotics are NOT recommended for patients with interstitial (uncomplicated) pancreatitis, regardless of severity. They do not prevent progression to infected necrosis.

Cause & Crisis - Why & How Bad?

Etiology: 📌 I GET SMASHED
- Idiopathic, Gallstones, Ethanol (most common)
- Trauma, Steroids, Mumps, Autoimmune
- Scorpion sting, Hypercalcemia/lipidemia, ERCP, Drugs
Severity Assessment: Triage tool to predict mortality & necrosis.
- SIRS Criteria: ≥2 indicates high risk (Temp <36/>38°C, HR >90, RR >20, WBC <4k/>12k).
- Lab Markers: ↑ BUN, ↑ Hematocrit (hemoconcentration), ↑ CRP are poor prognostic signs.
- Scoring: BISAP score is a simple bedside tool.

⭐ An increasing BUN during the first 24 hours is one of the strongest independent predictors of mortality.

Support & Sustenance - The Core Care Plan

NPO (Nil Per Os): Initially rest the pancreas. Advance diet to low-fat solids as pain and nausea resolve; no need for a clear liquid phase.
IV Fluid Resuscitation: Crucial to prevent necrosis.
- Aggressive hydration: 5-10 mL/kg/hr of isotonic crystalloid solution.
- Lactated Ringer's is preferred.
- Goal: ↓ BUN & hematocrit, urine output > 0.5 mL/kg/hr.
Analgesia: IV opioids (e.g., hydromorphone, fentanyl) are mainstays for severe pain.
Nutritional Support:
- If unable to tolerate oral diet by day 3-5, start enteral nutrition.
- Nasogastric or nasojejunal routes are both effective.

⭐ High-Yield: Lactated Ringer's is superior to Normal Saline as it may reduce the incidence of Systemic Inflammatory Response Syndrome (SIRS).

Acute Pancreatitis IV Fluid Management Algorithm

Complications - When Things Go Wrong

Local Complications
- Pancreatic Pseudocyst: Encapsulated fluid collection developing >4 weeks after acute pancreatitis. Often asymptomatic. Intervene (drainage) only if symptomatic, infected, or >6 cm and persistent.
- Pancreatic Necrosis: Most severe local complication. Can be sterile or infected.
Systemic Complications
- ARDS, pleural effusion (often left-sided), atelectasis
- Hypocalcemia (from fat saponification), hyperglycemia
- Acute kidney injury

⭐ Infected necrosis is the primary driver of mortality. Gas bubbles on a CT scan are pathognomonic for infection by gas-forming organisms and mandate urgent intervention.

CT scan: Infected pancreatic necrosis with gas bubbles

Aggressive IV hydration is the most crucial initial step to prevent pancreatic necrosis.

Pain management with IV opioids is a priority.

Start enteral nutrition early if oral intake is not tolerated; avoid TPN.

Prophylactic antibiotics are not recommended; use for confirmed infected necrosis only.

ERCP is indicated within 24-48 hours for severe gallstone pancreatitis with cholangitis.

Monitor closely for systemic complications like ARDS, hypocalcemia, and renal failure.

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Management of acute pancreatitis