Examqo › Examqo library › Internal medicine › Gastroenterology and hepatology · IMLE
Acute pancreatitis
The diagnosis rests on two of three (typical pain, lipase or amylase above 3 times normal, imaging), severity rests on persistent organ failure (Atlanta), and treatment is moderate fluids, early feeding and treatment of the cause — with no prophylactic antibiotics and no routine CT on admission.
Why it matters in the exam
A typical question presents severe epigastric pain radiating to the back with vomiting, after a heavy meal or drinking. The candidate must know that CT is not needed for the diagnosis when the pain and enzymes are typical, and that CT is reserved for an unclear diagnosis or a patient not improving after 48–72 hours. The commonest causes are gallstones and alcohol, followed by hypertriglyceridaemia (above 1000 mg/dL), hypercalcaemia, ERCP and drugs. That is why every patient has a biliary ultrasound and a triglyceride and calcium check.
Treatment questions test several ideas that have changed in recent years: moderate fluids (Ringer lactate) rather than aggressive fluids, which caused harm in a trial; early oral feeding within 24–72 hours as tolerated, and enteral rather than parenteral nutrition when needed; no prophylactic antibiotics, not even for necrosis. Urgent ERCP is done only for cholangitis or persistent obstruction, and in mild gallstone pancreatitis the gallbladder is removed during the same admission. Infected necrosis (gas on CT or deterioration after a week) is treated with an antibiotic (a carbapenem) and step-up drainage delayed as long as possible until the necrosis is walled off, usually after 4 weeks.
Key points
- Diagnosis: 2 of 3 — pain, lipase above 3 times normal, imaging.
- Causes: gallstones, alcohol, triglycerides above 1000 mg/dL, calcium, ERCP, drugs.
- Severity by organ failure: beyond 48 hours = severe.
- Treatment: moderate fluids, early feeding, no prophylactic antibiotics.
- Gallstones: ERCP only for cholangitis; cholecystectomy in the same admission.
Summary table
| Topic | Criterion | Action | Exam note |
|---|---|---|---|
| Diagnosis | 2 of 3: pain, lipase or amylase above 3 times normal, imaging | Biliary ultrasound, triglycerides, calcium | CT only if the diagnosis is unclear or no improvement after 48–72 hours |
| Severity (Atlanta) | Mild: no organ failure; moderate: transient failure or local complication; severe: failure beyond 48 hours | Monitoring, ward or intensive care | Persistent organ failure = high mortality |
| Fluids | Moderate Ringer lactate | Guided by urine output, heart rate and BUN | Aggressive fluids increase fluid overload |
| Nutrition | Oral feeding within 24–72 hours as tolerated | Enteral if not eating | Not parenteral when enteral is possible |
| Gallstones | Cholangitis → ERCP within 24 hours | Cholecystectomy in the same admission for mild disease | No routine ERCP without cholangitis or obstruction |
| Infected necrosis | Gas on CT or deterioration after 7–10 days | Carbapenem; step-up drainage after 4 weeks | No prophylactic antibiotics in sterile necrosis |
Free exam questions
מי מה מטופלים ה באים נמצא בסיכון ה מוגבר ביותר לפתח פנקראטיטיס אחרי Endoscopic retrograde cholangiopancreatography (ERCP) ? (the question as examined, in Hebrew)
- א. מטופל מבוגר
- ב. מטופל עם ערכי בילירובין תקינים
- ג. מטופל עם הרחבת דרכי מרה
- ד. מטופל עם מ י ימת
גופת אישה בת כ-70 שנה נמצאה בביתה שכובה בתנוחה עוברית, כשהיא בתחתוניה בלבד, מתחת למיטה. פניה ועפעפיה נראו תפוחים ושיער הגבות דליל. בנתיחתה ובבדיקה ההיסטולוגית נמצאו כיבים ברירית הקיבה שבהם דימום, דלקת חדה במספר מוקדים בלבלב, ודלקת כרונית קשה בבלוטת התריס. כמו כן נמצא שינוי שומני קשה בכבד. בבדיקות המעבדה נמצאו TSH = 10 mIU/L, fT4 = 0.6 ng/dL. מהי סיבת המוות? (the question as examined, in Hebrew)
- א. דלקת חדה בלבלב (acute pancreatitis)
- ב. תת-פעילות של בלוטת התריס (hypothyroidism) ומיקסאדמה
- ג. תת-חום (hypothermia)
- ד. תסחיף שומן
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Medical licensing exam (IMLE), Internal medicine, General surgery, Emergency medicine, Dermatology and venereology, ENT and head and neck surgery, Family medicine, Forensic medicine, Geriatrics, Neurology, Diagnostic pathology, Pediatric surgery, Pediatrics, Plastic surgery, Diagnostic radiology, Cardiothoracic surgery, Urology.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- American College of Gastroenterology Guideline: Management of Acute Pancreatitis, 2024 — Diagnosis, fluid therapy, nutrition, antibiotics and timing of cholecystectomy
- Revised Atlanta Classification of Acute Pancreatitis, 2012 — Definitions of severity and local complications
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Acute and Chronic Pancreatitis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.