Start

Early course: 0-72 hr

Is there organ failure?

Later course: >72 hr

Evidence of severe disease or organ failure?

Late course: 7-28 days

Patient improving?

Beyond 28 days

Patient improving?

Yes

No

Admission to an ICU
Same orders as for floor admission
Central line placement
Evaluate need for assisted ventilation
Assess for bile duct obstruction
If bilirubin rising, consider urgent ERCP

Admission to medical/surgical floor
NPO, IV hydration (250-400 cc/hr)
Nasal oxygen
Frequent evaluation of oxygen saturation
Hematocrit daily/BUN twice daily for 48 hr
Serum electrolytes daily
Pain control

End

Yes

No

Early refeeding
Evaluate for etiology

If gallstones, early cholecystectomy
If alcohol, address psychosocial issues
If high serum TG, medical therapy

To ICU if patient not already there
Observe for biliary sepsis; if present, consider emergency ERCP
Enteral feedings (NJ or NG)
CT to evaluate for necrosis

Interstitial pancreatitis on CT without peripancreatic necrosis:

Continue supportive care
Observation

Pancreatic/peripancreatic necrosis on CT:

Continue supportive care
Enteral feedings
If infection suspected, consider antibiotics

Yes

No

Consider oral refeeding

If on antibiotics, consider FNA of pancreas for culture and change of antibiotics
If not on antibiotics and FNA negative, keep off antibiotics

Yes

No

Consider necrosectomy by endoscopic, radiologic, or surgical means

Consider refeeding
If patient cannot tolerate feedings, consider necrosectomy

NJ, Nasojejunal.