Acute pancreatitis at the IMT (Internal Medicine Training) clinical station is answered with a diagnosis, a cause, a severity statement and three things you will not do. According to NICE NG104, diagnosis is confirmed by a raised blood lipase or amylase, with CT if those are not raised; prophylactic antimicrobials are not offered; patients are not made nil by mouth without a clear reason; and severity is defined by organ failure that persists beyond 48 hours.

Key takeaways

  • NICE NG104 confirms acute pancreatitis on a raised lipase or amylase, and uses abdominal CT to confirm pancreatic inflammation when the enzymes are not raised.
  • Do not assume the cause is alcohol because the patient drinks; if gallstones and alcohol are excluded, look for hypercalcaemia, hyperlipidaemia, drugs, microlithiasis, hereditary and autoimmune causes, tumours and pancreas divisum.
  • Do not offer prophylactic antimicrobials; fluid resuscitation follows NICE CG174, with 500 mL crystalloid boluses over less than 15 minutes when indicated.
  • Moderately severe pancreatitis is organ failure that resolves within 48 hours or local or systemic complications; severe is organ failure persisting beyond 48 hours, per the revised Atlanta classification quoted by NICE.
  • Offer enteral nutrition within 72 hours of presentation in moderately severe or severe disease, and parenteral nutrition only if enteral feeding fails or is contraindicated.
  • Necrotic, infective, haemorrhagic or systemic complications mean advice from a specialist pancreatic centre and a discussion about transfer.

How do you recognise acute pancreatitis in the scenario?

Acute pancreatitis presents as sudden-onset upper abdominal pain, usually with nausea and vomiting, epigastric tenderness, fever and tachycardia, often with a history of gallstones or heavy alcohol intake. NICE NG104 describes exactly that picture, and the station will add a low blood pressure or a high early warning score to see if you notice.

Say that the differential for severe epigastric pain includes a perforated ulcer, a leaking aortic aneurysm and an inferior myocardial infarction, so an ECG and an erect chest X-ray come early even when the lipase is diagnostic.

What does the A to E assessment and first hour look like?

The first hour of acute pancreatitis is an A to E assessment with fluid resuscitation, analgesia and antiemetics, oxygen to target, and a catheter for hourly urine output. NICE NG104 defers the fluid detail to CG174, so quote CG174's indicators for urgent resuscitation.

  • Resuscitate if systolic blood pressure is below 100 mmHg, heart rate above 90, capillary refill over 2 seconds or cold peripheries, respiratory rate above 20, NEWS of 5 or more, or a positive passive leg raise
  • Use a crystalloid containing 130 to 154 mmol/L of sodium, 500 mL over less than 15 minutes, and reassess after each bolus
  • Analgesia titrated to effect, with antiemetics, and a nasogastric tube only if vomiting demands it
  • Bloods: lipase or amylase, full blood count, urea and electrolytes, liver function, calcium, glucose, triglycerides, CRP and an arterial blood gas with lactate
  • Hourly urine output from the start, because renal function is one of the organ systems that defines severity

Which investigations confirm the diagnosis and find the cause?

The investigations in acute pancreatitis are a lipase or amylase to confirm, liver function tests and an ultrasound for gallstones, calcium and triglycerides for the metabolic causes, and CT when the enzymes are normal or the patient is not improving. NICE NG104 says raised enzymes can occur in other conditions, so the clinical picture still has to fit.

The cause list is where marks are won. NICE tells you not to assume alcohol because the patient drinks, and once gallstones and alcohol are excluded to look for hypercalcaemia, hyperlipidaemia, prescription drugs, microlithiasis, hereditary and autoimmune pancreatitis, ampullary or pancreatic tumours, and pancreas divisum.

What are the severity definitions you must say?

The severity definitions in acute pancreatitis are the revised Atlanta terms that NICE NG104 adopts: moderately severe disease is organ failure that resolves within 48 hours, or local or systemic complications without persistent organ failure; severe disease is single or multiple organ failure persisting for more than 48 hours.

NICE does not endorse a particular scoring system, so if you name the Glasgow criteria say that they are a UK ward convention for early triage, not a NICE recommendation, and that the severity label is decided by organ failure at 48 hours. NICE also asks you to tell families that around 15 to 20 per cent of adults with severe acute pancreatitis die in hospital.

What is the definitive management of acute pancreatitis?

Definitive management of acute pancreatitis is supportive: fluids, analgesia, oxygen, early feeding, treatment of the cause, and no prophylactic antibiotics. NICE NG104 is explicit on all three of the things candidates most often get wrong.

  • Do not offer prophylactic antimicrobials; antibiotics are for proven or strongly suspected infection
  • Do not make the patient nil by mouth or withhold food unless there is a clear reason such as vomiting
  • In moderately severe or severe disease, start enteral nutrition within 72 hours and aim to meet requirements as soon as possible; parenteral nutrition only if enteral fails or is contraindicated
  • Infected or suspected infected necrosis: an endoscopic approach when anatomically possible, percutaneous when not, balancing prompt debridement against the advantages of delay
  • Treat the cause: stop alcohol, and plan definitive gallstone management with the surgical team before the next attack

When and to whom do you escalate acute pancreatitis?

Escalate acute pancreatitis to critical care as soon as there is organ failure, which means a persistently low blood pressure, hypoxia or oliguria despite resuscitation, and to a specialist pancreatic centre for advice and possible transfer if necrotic, infective, haemorrhagic or systemic complications develop. NICE NG104 phrases that referral as a requirement, not an option.

How do you hand over acute pancreatitis in one minute?

The acute pancreatitis handover states the cause, the severity so far and the fluid response. Situation: a 47 year old with gallstone pancreatitis, lipase markedly raised, 6 hours in. Background: known gallstones, no alcohol. Assessment: heart rate 110 and systolic 95 on arrival, improved to 120 systolic after two 500 mL boluses, urine output 40 mL an hour, lactate 2.1, no organ failure yet. Recommendation: continue fluids to urine output, analgesia, eating as tolerated, ultrasound tomorrow, and please recheck observations and gas at 4 hours and call critical care if the blood pressure or urine output falls.

What does the panel listen for in a pancreatitis answer?

The panel listens for no prophylactic antibiotics, no routine nil by mouth, feeding within 72 hours, the 48-hour organ failure definition, and a cause list that goes beyond gallstones and alcohol. In practice the discriminating sentence is the honest one: that severity cannot be declared at the front door. The internalmedicineinterview bank of 361 questions with AI-marked spoken practice drills that answer against the clock.

What are the common mistakes in a pancreatitis station?

  • Starting antibiotics because the CRP is high
  • Writing nil by mouth as reflex
  • Requesting an immediate CT that will not change management on day one
  • Assuming alcohol and never checking calcium or triglycerides
  • Declaring the attack mild at 2 hours, before the organ-failure clock has run

How this comes up at the IMT interview

Acute pancreatitis maps onto the IMT clinical station as a resuscitation-and-restraint scenario. Investigations and diagnosis is the lipase, the cause list and the severity definition; management is fluids per CG174, analgesia, early feeding and no antibiotics; communication is explaining to the patient and family that recovery from severe disease can take at least three times the length of the hospital stay, which NICE asks you to say. The handover minute is scored on the fluid response, the urine output and the named trigger for calling critical care.